This is one in a series of articles, running between Thanksgiving and January, examining the relationship between housing loss and death in San Francisco. Check out the previous articles in the series, Looking for death, Gunpowder on the streets, and Will losing your home kill you?, Hidden in plain sight: dying and homelessness, and Be selfish: Give a gift to a homeless person and The Tenderloin: substance abuse and Nate, Starving in the Financial District: Ken and food insecurity, The Sixth and Mission Death Corridor: Assaults, brain trauma and homicide and Steve, Tori and the Western Addition: raising children without a stable bed.

I noticed Mary’s* coat right away. Even in the draftiness of our WPA-era homeless clinic, the bulkiness of her hip-length coat was impressive. Especially since she had obviously, long before I rushed into the exam room, removed her coat, put the faded blue johnnie on top of all her clothes, then put the coat back on top – and re-zipped the front up to her chin, hood pulled up. She sat on the edge of the mauve, cracked-pleather exam table, hunched, her arms tight across her middle, with the tails of the johnnie peeking out like a petticoat from under her coat.

Mary had a bad cough, and she didn’t make eye contact. I advanced on her, trying to move fast enough to salvage my day’s productivity quota. I am embarrassed to say that it was only when I began to lift the bottom of her coat to listen to her lungs and she flinched in reaction, only then did I finally begin to pay attention. I dropped her half-lifted coat hem, one-handed the stethoscope, unused, out of my ears, and stepped back. I noticed she had begun to rock in place.

It took a while, me making myself lean back against the counter, asking soft questions about this and that minor health subject, letting her talk, waiting for her, in case what I feared might be there, wrapped under layers.

It was.

She’d slept one night in the Mission District under a bush, and woke in the dark when someone grabbed her ankle. Four men held her down and raped her. Now, almost three months later, she spoke in a flat, detached voice like this was somehow normal, just another blank to be filled in like her cough, or whether she had an allergy, her eyes drifting all around the room. No, she hadn’t reported it – the idea seemed somehow foreign to her. No, she hadn’t seen them since and, well, as she said, it was dark and she didn’t want to turn her face and look at them while it was happening – and she couldn’t go back to that area of town ever again, which was a shame since she left her stuff, but it was all probably gone by now anyway. No, she hadn’t been examined or seen by anyone afterward. And no, she hadn’t had a period since.

Mary was no fool. Her drifting voice and emotionless eyes weren’t because she didn’t understand. What she was, as clearly as any WWI trench-warfare, or POW camp survivor, was shell-shocked. Something had broken inside. It was clear that just getting her to open her coat would involve establishing a significant degree of trust. All I could think, as I left the room to make many phone calls, was thank GOD we haven’t yet zeroed out the budget for the fabulous staff at SFGH’s Rape Crisis.

Mary* is one of a multitude of women being brutalized, raped, and murdered on our sidewalks. Often while we sleep one wall away. Pearla Louis’ life and death is a stark case study of what often happens to women on the street. You may think Pearla situation is not so common, but studies show that after an inability to afford rent, domestic violence is the next most common reason for the homelessness you see around you in San Francisco.

And homelessness from domestic violence affects women from every social and economic group. While you may be thinking to yourself, “hey, don’t we have battered-women shelters?,” you may not know that there are only 80 beds, total, for a city of over 800,000. And those 80 beds are for women and their children both, and the length of time that a family needs, and occupies, those beds can last for many weeks at a time.

Which means that the street may be the only place to flee after a near-fatal event, or when you’re evicted because of domestic violence, or when you’re denied your whopping multi-month rental deposit refund because you broke your lease to flee. The street also may be the only option for many especially because years of living with a controlling abuser also typically means that the woman has been verbally or physically battered into cutting all her social ties outside the abusive relationship.

But even if you’re a woman and end up on the street for other reasons, being abused and/or raped like Mary is likely to become the norm for you. Homeless assaults (both physical and sexual) and deaths are not gender-neutral. No group among those without a home dies faster, or more brutally, than women. Homeless women have higher rates of PTSD (65%) than returning combat veterans. Women die at shockingly high rates – not only losing their usual survival advantage over men, but also going further, to die at even higher rates then their age-equivalent male counterparts. And the group of women dying the most is young women.

What We Know:

Our own UCSF’s Kelley Knight and Elise Riley have made a detailed science out of this previously-only-an-anecdote issue – thereby documenting the factors, human toll, and health costs for all to see. To achieve this, they have done what many would consider the impossible – finding, and following over time the most fragile, the most brutalized, and the most self-hidden traumatized people in America – homeless women. Even if you’re averse to scientific jargon, reading their studies results in a deeply disturbing mix of reactions – simultaneously horrifying, mesmerizing, and inspiring in its sophistication and pragmatism.

Here are some of their take home points about our San Francisco women who are being brutalized outside our doors (here and here and here):

a) In cities throughout the United States, the estimated

growth in homelessness within certain neighborhoods is

as high as 25% per year, resulting in about 1% of the total

US population experiencing homelessness each year {a figure that mirrors San Francisco’s 1 in 100 proportion exactly}.

b) Violence from random people is shockingly common. And being unable to meet basic subsistence needs (such as an adequate supply of food) is strongly associated with becoming a victim of physical and sexual violence among HIV positive poor urban women. From an abstract presented at American Public Health Association’s conference: “All types of violence were more commonly perpetrated by persons who were not primary partners, suggesting that most of the violence against urban poor HIV+ women is not domestic violence. While heavy alcohol use is a behavior that can be changed, unmet subsistence needs and race are not immediately modifiable and put women at higher risk for violence. Addressing basic subsistence needs could serve to reduce violence against HIV+ urban poor women. Further, the data suggest that focusing on domestic abuse may miss most of the violence taking place in this population.”

c) One out of every ten women without a home is being raped each year. These largely-outdoor rapes are occurring on San Francisco’s sidewalks and in the foliage of our parks.

c) Women’s attempts at HIV risk reduction behaviors, such as

requesting condoms during sex, have been associated with

increased intimate partner violence.

d) “Health care and service providers cannot rely

on impoverished women to do what is “best” for their

health because poor women do not often have the agency

or means to do so.” And, as Dr. Leigh Kimberg, our local domestic violence DPH expert points out, “sometimes staying with an abusive partner might be considered better than being on the street where you can be sexually and physically abused by an unknown number of strangers.”

e) African American race may be relatively protective against some types of assault on the streets.

f) Finally, and most heart-breaking of all, the only thing it takes, to significantly lower the rates of sexual and physical abuse against women, is to give a woman a door to lock. Even if that door is in a suboptimal area. That’s all it takes.

What Works:

Leigh Kimberg has devoted much of her professional life as a physician to convincing the world that women’s suffering and death shouldn’t be ignored. She has shown that you can create, and increase the rates, of domestic violence screening in shelters. She has created training modules that have reached thousands of people. And she has been on the forefront of teaching others that death, pain, and disability at the hands of an intimate partner is an actionable public health issue. One that reaches far into our next generation. Long after it occurs today.

Casa de las Madres is known among people on the street. Respectful, welcoming, and safe, they do what we all wish someone could be there to do. If only they could be doing more of it…

Finally, a large network of people have worked tirelessly to try to change the path from domestic violence to homelessness. More and more cities are recognizing the large proportion of vulnerable people who end up on our streets because of DV. Recent laws have passed that prevent a person from being evicted because of domestic violence, and allow a person who breaks their lease due to DV to keep their deposit.

And here are four videos where Melodie, a homeless woman, Drs. Kelly Knight and Elise Riley, with our own DPH’s domestic violence expert, Leigh Kimberg, M.D., and Jamie Cox of La Casa de las Madres discuss interesting insider angles you didn’t already know about the lives of homeless women:

1) Money terror:

2) Impossible choices:

3) Brutalized into homelessness:

4) No woman is an island:

Stay tuned for one more in The California Endowment Health Journalism Fellowship series of articles by Doc Gurley on homelessness and mortality: Celebrating successes! This article was produced as a project for The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communication & Journalism.

*Identifying traits are changed to protect confidentiality, and accompanying street photos are NOT of patients.

You can support future articles looking at the role of the prison system in creating and concentrating homelessness here in California – go to Spot.us to donate time, money or earn credits for support! Doc Gurley is a Harvard Medical School graduate and is a practicing board-certified internist, and the creator of the Memoriam app – the first, and only, app to allow disaster-relief workers to speak for the dead. You can follow Doc Gurley on Facebook. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific, effective, affordable tips on how to nurture your joy and grow your personal wellth.