Americans are so sleep deprived that the Centers for Disease Control and Prevention has classified it as an epidemic. For homeless people in the United States, the problem goes much deeper.

“Having to live without a place that is home is tiring—physically, mentally, emotionally, in every way,” said Bobby Watts, CEO of the National Health Care for the Homeless Council. “Your need for sleep is greater, but your ability to get sleep is even less than if you were living in a home.”

Medical experts and advocates consider sleep deprivation an “unrecognized problem” among homeless patients that can lead to a number of physical and mental health issues. A recent court ruling affirmed that homeless people, too, have the right to sleep.

On September 4, the Ninth U.S. Circuit Court of Appeals sided with six homeless individuals from Boise, Idaho, who sued the city over a local ordinance that banned sleeping in public spaces. The decision prohibits cities from prosecuting people for sleeping in public when they have nowhere else to go, since it amounts to cruel and unusual punishment, which is unconstitutional.

“What that ruling said is these are basic human needs that are necessary for living,” said Watts, who applauded the court’s decision. “We fail, as a society, to look at the common needs that we all have. Instead, we look at some behaviors, sometimes caused by those very needs, and assign blame.”

Certain homeless populations, including women, domestic violence survivors, parents with children, people with disabilities, and others, are especially affected by such blame. Lack of sleep can make it more difficult for people to access resources they need to get back on their feet, and it contributes to the stigma of homelessness.

Too often, the homeless are stigmatized simply because they don’t have a safe place to sleep, with people sometimes quick to judge when they see a homeless person sleeping in public, Watts said. “They’re sleeping on the sidewalk, because they’re too lazy,” Watts told Rewire.News, referring to some of these beliefs. “They’re nodding off on the subway car because they’ve been up all night drinking—without seeing sleep as a basic human need. So, it just further stigmatizes people for the conditions under which they are living.”

Joseph Benson, a community health worker at Healthcare for the Homeless Houston, said the stigma stems from the fact that many homeless individuals stay awake all night and sleep during the day.

“If you’re not sleeping in a group where individuals are taking the time to stand up and watch over you, things happen,” he told Rewire.News. “For example, you can get robbed, people get beat up, women get raped, and some individuals get killed. So, the majority of the homeless community walks all night, and then sleeps in the daytime when the, I guess you’d say, the normal community is out going shopping or going to school or going to work or whatever.”

“That’s why you find so many homeless individuals in doorways and alleys and at the bus stops sleeping because they feel safe,” he said. “They feel that if they’re sleeping out in the open when the rest of the community is out, they feel protected.”

Benson has experienced this firsthand. He was homeless for four and a half years in the 1990s, and regularly slept under an expressway bridge. He said his first and only shelter experience was “the worst experience anyone could ever have.” As a double amputee who uses a wheelchair, Benson recalled that the shelter where he stayed wasn’t Americans with Disabilities Act-compliant, and the showers were on the second floor. He had to pull himself and his wheelchair up the stairs, shower in his wheelchair, get dressed, and get back down the stairs while soaking wet. “I never went back,” he said.

Sleep deprivation increases the risk for diabetes, hypertension, obesity, and memory loss, according to a National Health Care for the Homeless Council report. It can also impair cognitive function and lead to alcohol or drug use.

Besides the health effects, Benson said lack of sleep can cause people to miss job interviews and appointments for housing and other benefits. It can also make holding down a job tough, which can make getting out of homelessness difficult.

For domestic violence survivors, who often experience post-traumatic stress disorder and may find themselves homeless, the effects of not sleeping can be heightened, said Ruth Glenn, president and CEO of the National Coalition Against Domestic Violence (NCADV).

“A symptom of PTSD and other trauma is sleeplessness, depression, anxiety, and we’ve heard that the safest time to sleep is during the day because you need to be aware at night. So, there’s a hypervigilance that goes with it,” Glenn told Rewire.News.

Laura Cowan says her first night at a shelter was stressful and sleepless. It was 1999, and she and her three children had escaped a domestic violence situation where they were held captive and suffered abuse.

“I kept think thinking I heard his voice,” she said, referring to her former husband and abuser. “The children couldn’t sleep. They had nightmares, bed wetting, and couldn’t eat.”

Cowan, now a domestic violence advocate who works with the Cuyahoga Metropolitan Housing Authority in Cleveland, Ohio, explained that the stress and lack of sleep made it difficult to make decisions.

“When you’re in that situation, your abuser is constantly after you, and you can’t sleep,” she told Rewire.News. “You’ve got to almost keep one eye open.”

Sleep problems can persist even after getting out of dangerous and homeless situations. Cowan says following therapy and getting back on her feet, it took her about a year to find a regular sleep cycle.

Benson also couldn’t sleep after moving off the streets and into an apartment. He said he felt guilty getting housing while his friends remained on the street, and the quietness was unsettling.

“I was lucky that the apartment that I had had a balcony,” he said. “I slept on my balcony for the first six months before I was able to sleep in the house.”

Advocates involved with the Idaho case hope the decision will spark cities to enact real solutions to the issues faced by homeless people, “rather than just create more barriers and fill more jails with persons who only needed a place to sleep for the night,” said Howard Belodoff, of Idaho Legal Aid Services, in a press statement. NCADV’s Glenn told Rewire.News that addressing sleep should be one of the primary interventions that advocates, social workers, and others who work with the homeless and domestic violence victims provide.

“The first thing we want survivors of domestic violence and homelessness to do is make a lot of decisions,” she said. “We give them a checklist or we give them all of these things that they have to do to move forward. But, we’re not realizing that they may have gone for hours, days, weeks without sleep. How can you make a good decision?”

“We give them a lot of decisions to make about their lives and then we expect them to be OK, and a lot of times they just haven’t had enough rest.”