JOLJRh AL OF ADOLESCENT
HEALTH
19%;12:500-503
The Medical Care of Street Yout RQBERT W. DEISHER,
M.D.,
AND
WILLIAM
Our clinical contacts with street youth support the vrew that their numbers are growing and that their medical needs are largely neglected. We describe our experience in providing medical care to street youth in Seattle, with attention to their medical presentationa and patterns of health care utilization. We address aspects of adolescent street life that are unique to that particular mode of living or importantly formative in the lives of persons drawn to it. KRY WORDS:
Street youth Homeless youth Runaway youth
M. ROGERS II, M.D.
Medical problems presented by street youth vary from those commonly seen in adolescents to more serious and chronic conditions. The general disregard that figures so prominently in the lives of these young people has resulted in neglect of their basic medical care.
Medical Care Sample and Results In Seattle, services specifically designed for street
youtks are offered at evening clinics located at three central sity sites. The oldest of these clinics has been in continuous operation for 18 years. Each clinic is located in an area where street kids congregate, and each offers free services one evening per week. Two Our experience in providing medical services to of these clinics occupy fac!.lities that are open d:tring srreoi youth in Seattle has been instructive regarding the day as low-cost health care facilities for central this population’s medical needs and the forces that city residents. A third facility is located in a multiencourage and sustain street life among adolescents. service drop-in center for street youths operated by In a 1979 study of Seattle street youth, Bayer (1) a private community service organization. Ail three found that 75% of female adolescent prostitutes and of these clinics are staffed by the same medical per63% of male adolescent prostitutes in her study popsonnel, which is clearly conducive to continuity of ulation had been sexually abused. A study, by the care for our target population, United States Department of Health and Human From June 1982 through May 1987,1,403 patients Services (2) of runaways in southern California remade 2,624 visits to these two clinics, resulting in ports that 36% left home because of physical or sex4,904 diagnoses (Table 1). Of this population, 805 ual abuse and 44% ran from other severe long-term patients were male and 598 were female. Our diproblems. Nearly all of the street youth whom we agnostic technology included microscopes and a have seen in our clinics have histories of significant simple u.rine pregnancy test. Specimens obtained for abuse and neglect, and well over half-male and diagnosis of suspected sexually transmitted diseases female-have been involved in intermittent or full(STD) were processed by the municipal public health time prostitution. laboratory. Other relatively simple assays were provided by local hospital laboratories. Gynecologic and obstetric concerns, STD, and FWI theDepartment of Pediatrics (R. W.D.), Division ofAdolescent Medicine, University of Washington School of Medicine, Seattle, Wash_ dermatological complaints accounted for nearly half ington. and the Department of Pediatrics (W.M.R.), Children’s Hospital of the diagnoses. Requests for oral contraceptives Medical Center of Northern California, Oakland, Californh. and pregnancy testing constituted the vast majority Address rent requests to: Robert W. Deisher, M.D., Department of Pediatrics, Division ofAdolescent Medicine, University of Washing_ of gynecologic and obstetric services provided (Table ton SchoGZof Medicine, Seattle, WA. 2). !xo
1054_139x/9l/$3,30
0 Society for Adolescent Medicine, 11991 Published by Elsevier sdence Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
November 1991
THE MEDICAl CARE OF STREET YOUTH
Table 1. Diagnostic Categories 1982~hday 1987) .Diagnosis
for Street Youth (June
Sexually transmitted disease (STD) Gynecologic and obstetric (Non-STD) Contraception and pregnancy Other gynecologic Total Dermatological Routine health maintenance Respiratory Trauma Psychiatric Gastrointestinal Cardaovascular OphthalmcJogical Miscellaneous Total
.*_-
Table 2. Obstetric and Gynecologic
Services
Service Ft
(%I
790
(16Y;
768 98 866 646 644 597 337 272 185 90 88 389
‘(18%) (13%) (13%) (12%) (7%) (6%) (4%) (2%) (2%) (7%)
4,904 (100%) s_
Requests for oral coedtrareptives Side efierts of oral contmceptives Requests for othe 1 contraceptive services Condoms Foam Sponge Diaphragm IUD (including removal, problems) Total Pregnancy testing Abortior: refel: irl Post-abortion care Noninfectious vaginal and vulvar problems .Li’bnormalPap smear results Endometriosis Amenorrhea and oligomenorrhea Miscellaneous
50x
)I
(%I
338 21
(39%) (2%)
220 221 24 16
(14%) (26%) (3%) (2%)
19 15 15 16 61
(2%) (2%) (2%) (2%) (6%)
a2 20 11 4 3
IUD, intrauterine devic’e.
A variety of STD was diagnosed in our clinics (Table 3). The incidence of pharyngeal and rectal gonorrhea among females is noteworthy. Our data concerning suspected or proven infection with the human immunodeficiency virus (HIV) reflect conditions in the early-to-mid 1980s and may or may not underrepresent the current prevalence of HIV infection and related disease among street youth. There is intense cuttcern that prostitution, promjscuity, homosexuality, and intravenous drug use are concentrated in this pay-ulation in an ominous constellation of risk factors for the acquired immunodeficiency syndrorrne (AIDS). To date, WC have seen a total of seven cases of AIDS in our clinic populatioin. Our experience offers scant encouragement that this population can be successfully mobilized to adopt appropriate precautions against HIV transmissio\a. The prolonged, idiosyncratic incubation period associated with HIV infection confounds efforts at edilcation among street yocth, many of whom have heen slow or reluctant to alter established drug and sexual practices in the absence of overt symptoms. We inclrrde “safe sex” education efforts in all clirlica!lcontacts with street youth. Condoms and AIDS information are available at no cost any time that our clinics are open. Problems encountered in AIDS education have underscored the fact that, although these youths are active sexually, tk:eir knowledge of the anatomical, physiological, and psychological a@ects of sexuality is no more advanced than that of other adolescents. Health care providers should not assume that levels of sexual knowledge are consistent with Ilzels of activity.
The dermatological diagnoses (Table 4) are similar to those that wculd be expected among adolescents in general, althc:ugh the high incidence of infestations with lice and scabies in our clinic population is remarkable. Not surprisir,gly, expressed concerns of drug and alcohol use far underestimate the extent of these problems as we casually perceived them. However, our clinic charts did not routinely record information on drug use ur%s related medical problems (e.g., Table 3. Sexusily
Transmitted
Diseases (STD)
STD
n
Vaginitis Urethritis Venereal warts Pelvic inflammatory disease (PID) Cervicitis (without PID) Known exposure to STD with a negative workup Routine negative STD screening (not associated with known exposure) Genital herpes HIV-related “Worried well” HIV positive Total Gonorrhea pharyngeal and rectal infections Males Females Total Syphilis Chancroid HIV, human immunodefrciency
virus
%
192 134 101 89 76
(24%) (17%) (13%) (11%) (10%)
67
(8%)
50 42
(6%) (5%)
18
(2%)
14 ’
8
2 13 (2%) 7 il%) 1 (< 1%)
502
JOURNALOF ADOLESCENT HEALTHVol. 12, No. 7
DaSFiER AND ROGERS
Table 4. Dermatolo&al
Dial?nosia
Acne Scabies Pubic and body lice
Head lice A&+ dermatitis,seborrhea,psoriasis Cell&t& impetigo
FoWulitis, boils, sebaceouscysts Panmychia Noni&ctious foot problems Piantarwarts Tinea pedis Tineacruns Tineaversicolor Tineacap&is Frostbite MoUuscumcontagiosum Mis&laneous mouth lesions (e.g., herpes) Other
Preventive health measures and health education (with particular regard to nutrition and sexuality) are of great importance for individuals whose home life, medical care, and education have been disrupted. Acceptance of unusual behavior and unconventional lifest$les is essential. Efforts to achieve leverage with these young people by capitalizing on feelings of. shame or guilt are uniformly counterproductive. ‘Well-meaning health professionals who are insensitive to the complexities of the problems faced by street youth have engendered suspicion, poor compliance, and passive-aggressive acting out through careless and superficial attempts at ostensibly ‘“corrective” action. It is therefore not uncommon for these youths to seek medical services at the fringes of the health care delivery system. They often seek emergency care at large urban hospitals when untreated or chronic conditions have advanced to the point where they can no longer be ignored. In many cases, they are not welcome in these facilities because they appear for emergency services late at night when they might easily be treated in conventional outpatient settings during the day. Street youths are often anxious to distinguish themselves from the severely incapacitated individuals commonly found in the adult street population, and therefore avoid free clinics serving the adult homeless. Other free or low-cost clinics may offer only daytime office hours, again reducing the likelihood that they will succeed in attracting street youth. Several collaborative arrangements have simplified the tasks of administering and operating our three clinics. Foremost among these has been the support of the University of Washington School of Medicine. Medical assistant: at all three clinics is provided by physicians, medical students, and fellows associated with the Division of Adolescent Medicine. Accordingly, the cost of providing profes-
will
Diagnoses n
6)
79 (12%) 66 (10%) 42 (10%) 13 (2%) 50 (8%) 44 7%) 41 (6%) 7 (1%) 36 (6%) 18 (3%) 19 (3%) 32 (5%) 6 (1%) 1 (< 1%) 7 (1%) 1 (C 1%)
acute intoxication or withdrawal) had prompted the visit. Similarly, these data fail to reflect our strong sense that psychosomatic elements influenced many presenting medical complaints. Nevertheless, we found that expressed psychosocial difticulties were significantly represented among our documented psychiatric diagnoses (Table 5). By way of comparison, runaways treated at a &tic for high-risk youth in the Los Angeles area had particularly high rates of syphilis, pelvic infIammatory disease, trauma, rape, hepatitis, uncontrolled asthma, and scabies (Brady, unpublished observations).
Di5cus5ion Fhysicians treating street youth in both outpatient and inpatient settings need to be aware of their often-neglected medical needs. All adolescents who have had lapses in their contact with physicians should have a thorough physical examination that includes ebtaintg both physical and sexual histories. Personal information must be gathered in an objective and nonjudgmental manner. The preeminent issues for adolescents involved in street life must be actively and constructively acknowledged if there is to be rapport and an ongoing relationship. These issues include drug abuse (and possibly drug addiction), venereal disease, pregnancy# core gender identity, sexual orientation, undermined selfesteem, depression, suicidal ideation, and conflict with parents, as well as the immediate consecprences of homelessness. Referrals related to these concerns
frequently
be necessary;
Table 5. Psychiatric Diagnoses Diagnosis Expressed psychosocial problems (depression, suicide, anxiety, family problems) Observed stress-related symptoms (nonpsychotic) Acute psychotic episode or severe mentalillness Ekpxessed problems with drugs and alcohol Acute drug intoxication Acute drug withdrawal Problems with sleep Bulimia Pseudocyesis
n
%
(33%) 09 75 (28%) 27 (10%) 55 (20%) 5 (2%) 1 (< 1%) 11 (4%) 4 (1%) 1 (< 1%)
November 1991
sional services has been kept extremely low. There is one important exception: Our efforts to secure psychological and psychiatric professional services for our patients have proven particularly difficult. Neverthe?.ess, by encouraging volunteer service and by involving physicians who are particularly interested in adolescents, a high standard of care can be maintained at low cost. Supplies, medications, and lab services offered free of charge (or at greatly reduced rates) by local hospitals and the Department of Public Health have further reduced operating expenses. We have never been encumbered by the need to seek annually renewable sources of funding for the majority of services that we provide. The involvement of physicians in training has had benefits far beyond financial savings. Street youths relate well to medical students and welcome the opportunity to share their personal and medical concerns with other young persons. The periodic turnover of medical students and fellows has been a renewable source of enthusiasm and vigor in the professional lives of both senior and beginning practitioners. It has also sustained the process of observing, questioning, and refining. The success of our efforts to provide medical care to street youth has depended importantly on sharing information and criticism freely among the health care practitioners and other voluitteers who offer their services. Growth in our patient load wa:: initially slow. In the first 2 years, we saw only a tew street kids on most evenings that We were open. However, referrals from youth service organizationsi outreach, and (most importantly) notoriety through word-ofmouth have resulted in a steady increase in the size of our patient load. Although most of our client population falls within the age range for adolescent medicine 12-21 years), we have seen both younger and older patients. However, once our patients reach the
THE METECALCARE OF STREETYOUTH
503
age of 25 years., we assist thr’rC in finding other sources of health care. These youths are far more mterested in our services than previously imagined. They are often wiliing to undergo medical evalu&ation wbule remaining distrustful of other adults in ihe helping professions, offering opportunities to health care providers for bo”rh medical and nonmeoical intervention. Street you& pose difficult dilemmas of promise and frustration for the practitioner. Those of us who work with them regularly are invariably struck by their tenacity, resourcefulness, and intelligencequalities typically absent from the stereotypic image of the drifti>; sociopathic delinquent. One could argue that they have exhibited exceptional initiative and creativity in arriving at difficult solutions to intolerable burdens of abuse and disorder at home. The persistence of these attributes in spite of the disorder an4 depression in their lives is c4rnce of the human yatential that remains. The p:i?Lsence of s&et youth in all urban areas should ‘Intensify our efforts to identify them and to intervcane responsibly. Apart from the importance of &SO2 7 .mg a seriously underserved population, knowledge of them will help us understand their place m a’!~?spectrum of alienating processes that affect our young :;cople. Initial chart reviews and data tabn;. -~I)II benefited from the efforts of J. Tolmas, M.D., former Fellow in Adolescent Medicine at tht University of Washington School of Medicine.
1. Boyer DK. Male prostitution: A cultural expression of male homosexuality. Dissertation Abstracts International, 1986; 47:1377A. University Microfilms International No. DA 8613141. 1. Office of the Inspector Genetd! for Region 10. Runaway and Homeless Youth: National Program Inspection. Seattle: U.S. Dept of Health and Human Services, 1983; 4-6.
HEALTH
19%;12:500-503
The Medical Care of Street Yout RQBERT W. DEISHER,
M.D.,
AND
WILLIAM
Our clinical contacts with street youth support the vrew that their numbers are growing and that their medical needs are largely neglected. We describe our experience in providing medical care to street youth in Seattle, with attention to their medical presentationa and patterns of health care utilization. We address aspects of adolescent street life that are unique to that particular mode of living or importantly formative in the lives of persons drawn to it. KRY WORDS:
Street youth Homeless youth Runaway youth
M. ROGERS II, M.D.
Medical problems presented by street youth vary from those commonly seen in adolescents to more serious and chronic conditions. The general disregard that figures so prominently in the lives of these young people has resulted in neglect of their basic medical care.
Medical Care Sample and Results In Seattle, services specifically designed for street
youtks are offered at evening clinics located at three central sity sites. The oldest of these clinics has been in continuous operation for 18 years. Each clinic is located in an area where street kids congregate, and each offers free services one evening per week. Two Our experience in providing medical services to of these clinics occupy fac!.lities that are open d:tring srreoi youth in Seattle has been instructive regarding the day as low-cost health care facilities for central this population’s medical needs and the forces that city residents. A third facility is located in a multiencourage and sustain street life among adolescents. service drop-in center for street youths operated by In a 1979 study of Seattle street youth, Bayer (1) a private community service organization. Ail three found that 75% of female adolescent prostitutes and of these clinics are staffed by the same medical per63% of male adolescent prostitutes in her study popsonnel, which is clearly conducive to continuity of ulation had been sexually abused. A study, by the care for our target population, United States Department of Health and Human From June 1982 through May 1987,1,403 patients Services (2) of runaways in southern California remade 2,624 visits to these two clinics, resulting in ports that 36% left home because of physical or sex4,904 diagnoses (Table 1). Of this population, 805 ual abuse and 44% ran from other severe long-term patients were male and 598 were female. Our diproblems. Nearly all of the street youth whom we agnostic technology included microscopes and a have seen in our clinics have histories of significant simple u.rine pregnancy test. Specimens obtained for abuse and neglect, and well over half-male and diagnosis of suspected sexually transmitted diseases female-have been involved in intermittent or full(STD) were processed by the municipal public health time prostitution. laboratory. Other relatively simple assays were provided by local hospital laboratories. Gynecologic and obstetric concerns, STD, and FWI theDepartment of Pediatrics (R. W.D.), Division ofAdolescent Medicine, University of Washington School of Medicine, Seattle, Wash_ dermatological complaints accounted for nearly half ington. and the Department of Pediatrics (W.M.R.), Children’s Hospital of the diagnoses. Requests for oral contraceptives Medical Center of Northern California, Oakland, Californh. and pregnancy testing constituted the vast majority Address rent requests to: Robert W. Deisher, M.D., Department of Pediatrics, Division ofAdolescent Medicine, University of Washing_ of gynecologic and obstetric services provided (Table ton SchoGZof Medicine, Seattle, WA. 2). !xo
1054_139x/9l/$3,30
0 Society for Adolescent Medicine, 11991 Published by Elsevier sdence Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
November 1991
THE MEDICAl CARE OF STREET YOUTH
Table 1. Diagnostic Categories 1982~hday 1987) .Diagnosis
for Street Youth (June
Sexually transmitted disease (STD) Gynecologic and obstetric (Non-STD) Contraception and pregnancy Other gynecologic Total Dermatological Routine health maintenance Respiratory Trauma Psychiatric Gastrointestinal Cardaovascular OphthalmcJogical Miscellaneous Total
.*_-
Table 2. Obstetric and Gynecologic
Services
Service Ft
(%I
790
(16Y;
768 98 866 646 644 597 337 272 185 90 88 389
‘(18%) (13%) (13%) (12%) (7%) (6%) (4%) (2%) (2%) (7%)
4,904 (100%) s_
Requests for oral coedtrareptives Side efierts of oral contmceptives Requests for othe 1 contraceptive services Condoms Foam Sponge Diaphragm IUD (including removal, problems) Total Pregnancy testing Abortior: refel: irl Post-abortion care Noninfectious vaginal and vulvar problems .Li’bnormalPap smear results Endometriosis Amenorrhea and oligomenorrhea Miscellaneous
50x
)I
(%I
338 21
(39%) (2%)
220 221 24 16
(14%) (26%) (3%) (2%)
19 15 15 16 61
(2%) (2%) (2%) (2%) (6%)
a2 20 11 4 3
IUD, intrauterine devic’e.
A variety of STD was diagnosed in our clinics (Table 3). The incidence of pharyngeal and rectal gonorrhea among females is noteworthy. Our data concerning suspected or proven infection with the human immunodeficiency virus (HIV) reflect conditions in the early-to-mid 1980s and may or may not underrepresent the current prevalence of HIV infection and related disease among street youth. There is intense cuttcern that prostitution, promjscuity, homosexuality, and intravenous drug use are concentrated in this pay-ulation in an ominous constellation of risk factors for the acquired immunodeficiency syndrorrne (AIDS). To date, WC have seen a total of seven cases of AIDS in our clinic populatioin. Our experience offers scant encouragement that this population can be successfully mobilized to adopt appropriate precautions against HIV transmissio\a. The prolonged, idiosyncratic incubation period associated with HIV infection confounds efforts at edilcation among street yocth, many of whom have heen slow or reluctant to alter established drug and sexual practices in the absence of overt symptoms. We inclrrde “safe sex” education efforts in all clirlica!lcontacts with street youth. Condoms and AIDS information are available at no cost any time that our clinics are open. Problems encountered in AIDS education have underscored the fact that, although these youths are active sexually, tk:eir knowledge of the anatomical, physiological, and psychological a@ects of sexuality is no more advanced than that of other adolescents. Health care providers should not assume that levels of sexual knowledge are consistent with Ilzels of activity.
The dermatological diagnoses (Table 4) are similar to those that wculd be expected among adolescents in general, althc:ugh the high incidence of infestations with lice and scabies in our clinic population is remarkable. Not surprisir,gly, expressed concerns of drug and alcohol use far underestimate the extent of these problems as we casually perceived them. However, our clinic charts did not routinely record information on drug use ur%s related medical problems (e.g., Table 3. Sexusily
Transmitted
Diseases (STD)
STD
n
Vaginitis Urethritis Venereal warts Pelvic inflammatory disease (PID) Cervicitis (without PID) Known exposure to STD with a negative workup Routine negative STD screening (not associated with known exposure) Genital herpes HIV-related “Worried well” HIV positive Total Gonorrhea pharyngeal and rectal infections Males Females Total Syphilis Chancroid HIV, human immunodefrciency
virus
%
192 134 101 89 76
(24%) (17%) (13%) (11%) (10%)
67
(8%)
50 42
(6%) (5%)
18
(2%)
14 ’
8
2 13 (2%) 7 il%) 1 (< 1%)
502
JOURNALOF ADOLESCENT HEALTHVol. 12, No. 7
DaSFiER AND ROGERS
Table 4. Dermatolo&al
Dial?nosia
Acne Scabies Pubic and body lice
Head lice A&+ dermatitis,seborrhea,psoriasis Cell&t& impetigo
FoWulitis, boils, sebaceouscysts Panmychia Noni&ctious foot problems Piantarwarts Tinea pedis Tineacruns Tineaversicolor Tineacap&is Frostbite MoUuscumcontagiosum Mis&laneous mouth lesions (e.g., herpes) Other
Preventive health measures and health education (with particular regard to nutrition and sexuality) are of great importance for individuals whose home life, medical care, and education have been disrupted. Acceptance of unusual behavior and unconventional lifest$les is essential. Efforts to achieve leverage with these young people by capitalizing on feelings of. shame or guilt are uniformly counterproductive. ‘Well-meaning health professionals who are insensitive to the complexities of the problems faced by street youth have engendered suspicion, poor compliance, and passive-aggressive acting out through careless and superficial attempts at ostensibly ‘“corrective” action. It is therefore not uncommon for these youths to seek medical services at the fringes of the health care delivery system. They often seek emergency care at large urban hospitals when untreated or chronic conditions have advanced to the point where they can no longer be ignored. In many cases, they are not welcome in these facilities because they appear for emergency services late at night when they might easily be treated in conventional outpatient settings during the day. Street youths are often anxious to distinguish themselves from the severely incapacitated individuals commonly found in the adult street population, and therefore avoid free clinics serving the adult homeless. Other free or low-cost clinics may offer only daytime office hours, again reducing the likelihood that they will succeed in attracting street youth. Several collaborative arrangements have simplified the tasks of administering and operating our three clinics. Foremost among these has been the support of the University of Washington School of Medicine. Medical assistant: at all three clinics is provided by physicians, medical students, and fellows associated with the Division of Adolescent Medicine. Accordingly, the cost of providing profes-
will
Diagnoses n
6)
79 (12%) 66 (10%) 42 (10%) 13 (2%) 50 (8%) 44 7%) 41 (6%) 7 (1%) 36 (6%) 18 (3%) 19 (3%) 32 (5%) 6 (1%) 1 (< 1%) 7 (1%) 1 (C 1%)
acute intoxication or withdrawal) had prompted the visit. Similarly, these data fail to reflect our strong sense that psychosomatic elements influenced many presenting medical complaints. Nevertheless, we found that expressed psychosocial difticulties were significantly represented among our documented psychiatric diagnoses (Table 5). By way of comparison, runaways treated at a &tic for high-risk youth in the Los Angeles area had particularly high rates of syphilis, pelvic infIammatory disease, trauma, rape, hepatitis, uncontrolled asthma, and scabies (Brady, unpublished observations).
Di5cus5ion Fhysicians treating street youth in both outpatient and inpatient settings need to be aware of their often-neglected medical needs. All adolescents who have had lapses in their contact with physicians should have a thorough physical examination that includes ebtaintg both physical and sexual histories. Personal information must be gathered in an objective and nonjudgmental manner. The preeminent issues for adolescents involved in street life must be actively and constructively acknowledged if there is to be rapport and an ongoing relationship. These issues include drug abuse (and possibly drug addiction), venereal disease, pregnancy# core gender identity, sexual orientation, undermined selfesteem, depression, suicidal ideation, and conflict with parents, as well as the immediate consecprences of homelessness. Referrals related to these concerns
frequently
be necessary;
Table 5. Psychiatric Diagnoses Diagnosis Expressed psychosocial problems (depression, suicide, anxiety, family problems) Observed stress-related symptoms (nonpsychotic) Acute psychotic episode or severe mentalillness Ekpxessed problems with drugs and alcohol Acute drug intoxication Acute drug withdrawal Problems with sleep Bulimia Pseudocyesis
n
%
(33%) 09 75 (28%) 27 (10%) 55 (20%) 5 (2%) 1 (< 1%) 11 (4%) 4 (1%) 1 (< 1%)
November 1991
sional services has been kept extremely low. There is one important exception: Our efforts to secure psychological and psychiatric professional services for our patients have proven particularly difficult. Neverthe?.ess, by encouraging volunteer service and by involving physicians who are particularly interested in adolescents, a high standard of care can be maintained at low cost. Supplies, medications, and lab services offered free of charge (or at greatly reduced rates) by local hospitals and the Department of Public Health have further reduced operating expenses. We have never been encumbered by the need to seek annually renewable sources of funding for the majority of services that we provide. The involvement of physicians in training has had benefits far beyond financial savings. Street youths relate well to medical students and welcome the opportunity to share their personal and medical concerns with other young persons. The periodic turnover of medical students and fellows has been a renewable source of enthusiasm and vigor in the professional lives of both senior and beginning practitioners. It has also sustained the process of observing, questioning, and refining. The success of our efforts to provide medical care to street youth has depended importantly on sharing information and criticism freely among the health care practitioners and other voluitteers who offer their services. Growth in our patient load wa:: initially slow. In the first 2 years, we saw only a tew street kids on most evenings that We were open. However, referrals from youth service organizationsi outreach, and (most importantly) notoriety through word-ofmouth have resulted in a steady increase in the size of our patient load. Although most of our client population falls within the age range for adolescent medicine 12-21 years), we have seen both younger and older patients. However, once our patients reach the
THE METECALCARE OF STREETYOUTH
503
age of 25 years., we assist thr’rC in finding other sources of health care. These youths are far more mterested in our services than previously imagined. They are often wiliing to undergo medical evalu&ation wbule remaining distrustful of other adults in ihe helping professions, offering opportunities to health care providers for bo”rh medical and nonmeoical intervention. Street you& pose difficult dilemmas of promise and frustration for the practitioner. Those of us who work with them regularly are invariably struck by their tenacity, resourcefulness, and intelligencequalities typically absent from the stereotypic image of the drifti>; sociopathic delinquent. One could argue that they have exhibited exceptional initiative and creativity in arriving at difficult solutions to intolerable burdens of abuse and disorder at home. The persistence of these attributes in spite of the disorder an4 depression in their lives is c4rnce of the human yatential that remains. The p:i?Lsence of s&et youth in all urban areas should ‘Intensify our efforts to identify them and to intervcane responsibly. Apart from the importance of &SO2 7 .mg a seriously underserved population, knowledge of them will help us understand their place m a’!~?spectrum of alienating processes that affect our young :;cople. Initial chart reviews and data tabn;. -~I)II benefited from the efforts of J. Tolmas, M.D., former Fellow in Adolescent Medicine at tht University of Washington School of Medicine.
1. Boyer DK. Male prostitution: A cultural expression of male homosexuality. Dissertation Abstracts International, 1986; 47:1377A. University Microfilms International No. DA 8613141. 1. Office of the Inspector Genetd! for Region 10. Runaway and Homeless Youth: National Program Inspection. Seattle: U.S. Dept of Health and Human Services, 1983; 4-6.
