A Primary Care Approach to Treating Women Without Homes

Roseanna H. Means, MD, MSc

In This Article

The Physical Exam

Women who sleep outdoors or in shelters have little experience with privacy. Because of the role of trauma, the physical exam must be performed when the woman is emotionally prepared to share her "space." The exam should address the presenting complaint by giving a clear explanation in advance of what is going to happen. Since one of the practitioner's goals is to engender a feeling of trust, no part of the patient's body should be touched without permission. This means that portions of the exam that pertain to preventive health guidelines may have to be set aside until the relationship is stronger.

Certain features of the exam can be obtained without threatening patients, such as taking blood pressure, observing some areas of the skin, cutting toenails, giving foot soaks, or performing brief oral exams. Nevertheless, patients who refuse any part of the exam must have their wishes respected.

Some women may refuse to permit the part of the exam that directly corresponds to their chief complaint. They may simply want to talk about it. In this case, the "chief complaint" may not be the chief problem. Whenever the clinician is confronted with "mixed messages" or a serious medical condition, a follow-up call (with the patient's permission) to a shelter or outreach group who may know the patient will help other caregivers know where she has been and to do follow-up outreach. In the big picture, the patient has less likelihood of being "lost to follow-up" when a network of individuals is looking out for her.

In homeless women, look for and document signs that reflect the lifestyle: poor overall hygiene, dental neglect, foot overuse, peripheral vascular disease, tattoos covering scars, other signs of drug abuse such as needle marks, skin popping, and nasal perforations. Also look for head or pubic hair infestations or scabies. Document signs of physical abuse: burns, scars, bruises, unattended fractures. Look for sequelae of chronic liver disease and STDs, including HIV.

Mood, affect, and behavior can be irritable, indifferent, bland, hypervigilant, paranoid, volatile, depressed, despairing, psychotic, disconnected, demanding, violent, irresponsible, distrusting, or manipulative. Some of these are symptoms of primary mental illness, some are signs of posttraumatic stress disorder, or responses to the trauma of street life, and some are the effects of chemical dependency. The mental and psychological issues cannot be sorted out in the beginning. What is important is that the practitioner document the findings and treat the woman in such a way that she feels safe and wants to return.

Gynecologic exams can be perceived as threatening and can elicit posttraumatic symptoms in women who have been victims of sexual trauma. After obtaining the patient's permission to do the pelvic exam, tell her what is involved while she is dressed and facing you. Sexually traumatized women may need time to prepare themselves emotionally. It is far less threatening if she has the opportunity to prepare herself while she has her clothes on. Women who may have a history of sexual abuse should never be left in the stirrups and abandoned while the physician answers a page or collects equipment. All equipment should be collected in advance and laid out within easy reach. The door to the exam room should be secure, and a female attendant should be present with male providers. Whenever pelvic exams are done, cultures for Neisseria gonorrhea and Chlamydia are recommended. A suggested approach to gynecologic exams is described in Table 5.


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