This nurse’s ‘pie in the sky’ is to revamp homeless women’s health care in Pittsburgh
Homelessness affects women differently than men, and according to Street Nurse Navigator Mary Sligh, homeless women need to have a dedicated space of their own.
Photo: A woman sleeps on the street in Nice, France by Ericd / CC BY-SA
By Ashlee Green
Last summer, close to eight women were pregnant and living on the streets in Pittsburgh.
The number was outrageous, even to Mary Sligh, who’s worked in homeless health care for her entire five-year nursing career. She and her colleagues knew they had to take action.
“We were like, ‘What the heck are we going to do about this?’” Sligh recalls.
Sligh made the discovery while she was doing general street rounds for her work as a street nurse navigator for the Allegheny Health Network’s (AHN) Center for Inclusion Health. She believes that homeless women who are pregnant often don’t access prenatal care because they don’t trust America’s health care system.
“Folks in general, in my experience, who are homeless or… living on the street often are very mistrusting of outsiders, particularly health care providers… and I think that’s particularly true with homeless women,” Sligh says.
It’s common, she says, for these women to not access prenatal care at all, and then show up in the emergency room to deliver their babies. This is just one example of how the lives of homeless women are misunderstood by health care providers. Interactions like these perpetuate what Sligh calls a “real shame storm” when homeless women try to access health services.
“If you’re going to the emergency room for a pregnancy test when you have recently used a substance… the perception… [is], ‘Why are you in the emergency room for this? You can go to your gynecologist,’” Sligh explains. Without insurance, though, it’s difficult for homeless women to even figure out the first steps to finding a gynecologist.
This puts a spotlight on a stark problem with this country’s current reality: the lives of women who are homeless do not fit into the framework of the U.S. health care system.
The path toward homelessness
Men and women often end up homeless for different reasons. While it’s true that poverty, limited affordable housing, and unemployment are major factors that lead to it for all genders, men are the ones who are more likely to be veterans and are less likely to seek treatment for substance abuse and mental health issues. Women, on the other hand, are often driven to homelessness after experiencing domestic violence. And it doesn’t end there.
“[Women] tend to, almost without fail, experience sexual violence on the street, typically perpetrated by men,” says Sligh. It’s not uncommon for women to exchange sex for a place to sleep—referred to as “survival sex”—either, Sligh explains.
“I think women on the street are so vulnerable because there’s no support; you’re just by yourself, trying to navigate the world by yourself, and maintain physical safety,” says Sligh. “If a man offers the promise of some level of security and safety, it seems as though it can be pretty tempting to latch onto that person, even if otherwise, the woman might be able to identify or might understand that that person is not a safe person.”
Shelters, too, can be risky places for women: the vulnerabilities of street life, such as assault and theft, Sligh says, extend into them. Simply put, homelessness tends to be more dangerous for women.
“… I think it’s really challenging to provide a space for women to just exist and be women without being harassed, abused, [and] coerced by men or other folks on the street,” Sligh says.
Sligh decided pretty fast in her role with AHN’s street medicine team that she wanted to find a way to specifically support women on the streets. She also knew that if she wanted to more easily gain her clients’ trust, she’d have to do it with an all-women team.
She joined up with her colleague Dana Lynch, a street outreach specialist with Operation Safety Net, Pittsburgh Mercy’s street medicine program. Then, she asked her friend Jean Fitzgibbons, a women’s health nurse practitioner with AHN’s Perinatal Hope Program, a rehabilitation program for pregnant women with substance abuse issues, to come out with her and Lynch on one of their Friday afternoon runs to check in on a woman who was pregnant. Fitzgibbons agreed to come along, and with that, “Fertile Fridays” was, well, born.
There was a learning curve at first, Sligh recalls.
“I, naively, would like to think that everybody likes nurses, but that’s certainly not always true,“ Sligh says with a laugh. “A habit that I’ve had to break is not introducing myself as a nurse, just introducing myself as Mary.” Interacting with people—women in particular, Sligh says—as humans first, rather than as patients who are looking to be helped or saved, can change the “transactional nature” of her interactions on the job.
Once Sligh and her colleagues realized that pregnant women weren’t the only ones who would benefit from their specialized care, and in fact all women could be helped, Fertile Fridays became a consistent Friday afternoon endeavor.
“We realized pregnant women aren’t the only women on the street who need care that’s relevant and meaningful to them, and prenatal care might not be the only thing that women are looking for on the street,” Sligh says. Access to abortion services, emergency contraception, and STI testing, she explains, is also important.
“Just routine gynecological care is something that’s not often accessible and low-barrier for women who are experiencing homelessness,” Sligh says. Mental health care, she adds, is vital too.
One week, Sligh, Lynch, and Fitzgibbons might go out to see one specific woman or multiple specific women. Another week—when the winter shelter is open Downtown, for example—they could just drive around and bump into people who could use their care.
“Sometimes we have scheduling conflicts or other patients we have to see, but we try to go out every Friday afternoon and see women—not just on the Northside, but all over the city,” Sligh says.
The women Sligh and her colleagues meet on the street who need greater care can make an appointment with Fitzgibbons through AHN Women’s Health; she has carved out specific times on Wednesdays for this special population.
Effects of COVID-19
Since the dawn of the COVID-19 pandemic, Sligh says she and the AHN street medicine team have seen certain trends in Pittsburgh’s homeless population; they’ve had to change up their normal operations as needed.
“We would expect [homeless camps] to be bursting at the seams this time of year, but they’re not.” Sligh says. She cites summertime as the season when travelers are normally hitching rides around the country and into Pittsburgh via freight trains.
Another change: the addition of face masks. Sligh’s team never would have thought about wearing masks on the street before, especially with people who tend to be distrustful. Now, though, she says it’s “kind of a non-negotiable.”
“We have to make sure that we’re protecting our patients,” Sligh says, even if masks are uncomfortable. They’ve decreased the number of staff people who do street rounds, too, and Fertile Fridays are on pause.
While Fertile Fridays may have less clout in Pittsburgh than street medicine does as a whole (it’s existed in the city for over 20 years now,) women can still be seen during general street rounds, Sligh explains.
“It’s exciting that the drive to make sure that homeless women still have care still exists, even if we’re not doing formal street rounds with women,” Sligh says.
The challenge of accessible resources
Resources do exist in Pittsburgh for women. There’s Bethlehem Haven, for example, which is a women’s shelter located in Uptown, as well as the Women’s Center and Shelter of Greater Pittsburgh in the East End and a few coed shelters in the city. The Center for Victims operates a 24-hour crisis hotline (1-866-644-2882) for victims of domestic violence and is slated to begin construction on their new emergency shelter in the Southside soon; Garden Home Ministries does work to counteract homelessness, addiction, and human trafficking through advocacy, outreach, and housing. Light of Life offers a women’s outreach location that they do not publicize, as well as programs for single women and women with children such as classes on education, employment, and recovery, and rent-subsidized apartments. Their new facility is underway on the North Shore and will provide an overnight shelter for women and children; it’s expected to be completed in the winter of 2021. Northside Common Ministries has a health care clinic that’s open to people who are homeless, and Northside Christian Health Center has a Federally Qualified Health Center (FQHC) designation, which means that in addition to accepting most health insurance plans, they’re able to offer their services for sliding scale fees for patients without insurance.
These resources can be challenging to access though, especially for those who are homeless. Even at AHN, Sligh says, it’s difficult for walk-in patients to be treated on the spot.
“… Essentially, we don’t really have a space where—currently, within the Center for Inclusion Health—where patients sort of just show up, walk in,” Sligh says. Primarily, the fixed-site locations that patients go to are either by appointment or by referral, but she would like to see this change.
“My personal opinion is that we could have a lot more opportunities to connect with folks if we had a way for folks to just kind of show up to receive care,” Sligh says. “That’s just not currently the way that our model is set up.”
Patients who are homeless can be seen in one of three AHN clinics on the Northside, including one for primary health care and another for medication-assisted treatment (MAT). Sligh says AHN is working to expand homeless health care throughout the health system as a whole.
“I’m really proud of the work that—especially in our [MAT] clinic—the way that the staff has been able to interact with our homeless patients and welcome them into care, but, if you can’t get past the front door, then it’s really hard to access those services.” She says that a clinical setting can be intimidating for people who are homeless, because of their common distrust of the health care system as a whole. This is especially true for women of color and transgender women.
“Often, just even an initial introduction or conversation with a woman on the street can be really challenging and take a long time to foster any sort of relationship because of the level of mistrust.”
Access to free, public space is diminishing. Because of this, people who are homeless are often limited to spending their time in public libraries, warming centers, and drop-in centers throughout the city. According to Sligh, though, women need a space of their own.
A new framework
Sligh and her colleagues are envisioning an alternative approach to today’s standard health care system; one that’s a better fit for their clientele. It looks something like HER Saturday, a project of the Boston Health Care for the Homeless Program (BHCHP). HER (which stands for Health, Empowerment, Resources) Saturday is a “health fair, coffee talk, crafting session and walk-in clinic, all rolled into one,” as one article describes it.
“They have arguably the most well-funded and most robust health care for the homeless program in the country, in Boston,” says Sligh. It’s held in the BHCHP headquarters in Boston’s South End.
“They close down the huge lobby on Saturday morning from 7 to 11 a.m., lock the doors, and the only people allowed in are women,” says Sligh. Obviously, people can come in and go as they want, but no men are allowed; only people who identify as women; not exclusive of transgender women.” Services offered at the program, Sligh explains, are robust.
“They have mental health care, physical health care… you can get your hair done, your nails done, do some crafts, watch a movie, group therapy, individual therapy, eat—they have food—and just exist in a space that’s not dominated by men.”
Sligh says the Pittsburgh version of a HER Saturday would be a drop-in center where Fitzgibbons would provide prenatal and gynecological care, STI testing, therapy, and a space where “… women can just get a shower and chill and smell a nice candle or something [laughs]—just exist away from the trauma of homelessness for a couple hours.”
Sligh and her colleagues were planning to attend a conference in Boston to visit a HER Saturday and observe for the day, but COVID-19 forced them to cancel their trip. Either way, offering something similar in Pittsburgh still remains a “pie in the sky” dream for them.
“So many drop-in centers and services that are provided for homeless folks are masculine spaces and dominated by men. Men are listened to more than women… men are so often provided an audience more than women… so men often get more services than women, because they’re willing and able to ask…,” says Sligh.
“It’s sort of like ‘the squeaky wheel gets the grease.’”
The power of listening
While Sligh admits that their own version of HER Saturdays is “pretty far from our current reality,” she and her team still have this low-barrier, ‘safe hub’ of sorts in their sights. In the meantime, they’re working on doing more of the same: making regular street rounds, connecting patients to care, and listening to them.
“When we first started doing Fertile Fridays, [Fitzgibbons] was doing a lot of asking women ‘What would you like out of a women’s health round on the street?,’” says Sligh. “Something that came up as a common theme was ‘We just would like to be listened to. No one listens to us.’”
She says homeless people can easily “disappear into the background and become invisible.”
“If you’re already invisible and then within the context of homeless services that are supposed to meet your needs, you’re still invisible, that is just especially ‘othering.’”
Sligh says she doesn’t know how she ended up in her current career, but she’s glad that she did.
“I really really love one-on-one interactions with my patients, and I feel like I am able to most closely communicate with my patients when I’m wearing my own clothes and [I’m] in their environment versus in scrubs and they’re in a hospital gown in a hospital bed,” she says.
“I wanted to be a nurse for a long time.”
If you have questions for Sligh, you can reach out to her at Mary.Sligh2@ahn.org.