Journal of Adolescence 36 (2013) 1205–1213
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Coming of age on the streets: Survival sex among homeless young women in Hollywood Curren W. Warf a, b, *, Leslie F. Clark a, b, Mona Desai a, Susan J. Rabinovitz a, Golnaz Agahi a, Richard Calvo a, Jenny Hoffmann c a
Division of Adolescent Medicine, Children’s Hospital Los Angeles, USA Department of Pediatrics, Keck School of Medicine, University of Southern California, USA c School of Medicine, University of California San Diego, USA b
a b s t r a c t Keywords: Homeless youth Prostitution Survival sex Adolescent behavior Child abuse Sexual Homeless children
This study examined childhood physical or sexual abuse, involvement in dependency or delinquency systems, psychiatric hospitalization, and suicide as possible risk factors for survival sex among homeless young women. Homeless young women were found to have similarly high rates of childhood sexual abuse, dependency and delinquency systems involvement, and psychiatric hospitalization. Homeless young women involved in survival sex disclosed higher rates of attempted suicide and reported marginally higher rates of childhood physical abuse. Analysis of qualitative data showed that those engaged in survival sex were motivated primarily by desperation to meet basic needs including a place to stay, food and money, and one third mentioned that peers commonly were influential in decisions to engage in survival sex. Others were influenced by coercion (10%) or pursuit of drugs (10%). Young women engaged in survival sex generally experienced regret and shame about their experience. Ó 2013 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
It is estimated that in the United States over one million youth under age 18 are homeless each year, about half of whom are females (Hammer, Finkelhor, & Sedlak, 2002). Estimates of homeless young adults ages 18–24 in the United States range from 750,000 to 2 million (Whitbeck, 2009); samples of the young adult homeless youth population are disproportionately male (Toro, Dworsky, & Fowler, 2007). The numbers of homeless youth and their profiles differ depending on the source of the data, definitions of homelessness used, age ranges of youth surveyed, and sampling strategies and methods employed (Toro et al., 2007; Toro, Lesperance, & Braciszewski, 2011; Whitbeck, 2009). Homeless young people consistently identify conflict with their parents as the primary reason for their homelessness (Robertson & Toro, 1999) (Toro et al., 2007), and conflicts related to step-parent relationships, sexual activity, pregnancy, sexual orientation, school problems, and alcohol and drug use contribute to youth homelessness (Toro et al., 2007). In addition, homeless youth often cite physical or sexual abuse from parents or caregivers as their reason for leaving home (Toro et al., 2007; Whitbeck, 2009). Regardless of the cause, homeless youth confront the challenge of surviving without the support of parents and family, with a poor education and without marketable job skills. As a result, many homeless young people turn to strategies such as panhandling, shoplifting, stealing, dealing drugs, and prostitution or survival sex (i.e.,
* Corresponding author. Division of Adolescent Health and Medicine, Department of Pediatrics, British Columbia Children’s Hospital, CSB V2.223, 950 West 28th Ave., Vancouver, BC V6K 1B1, Canada. Tel.: þ1 604 875 2000x4635. E-mail address: [email protected] (C.W. Warf). 0140-1971/$ – see front matter Ó 2013 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.adolescence.2013.08.013
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participating in sexual acts in exchange for money, food, lodging, clothing, or drugs) in order to survive (Ferguson, Bender, Thompson, Xie, & Pollio, 2011; Greene, Ennett, & Ringwalt, 1999; Robertson & Toro, 1999; Tyler & Johnson, 2006; Whitbeck, 2009). Estimates range that from 10% to 50% of homeless youth become involved in survival sex (Greene et al., 1999; National Alliance to End Homelessness, 2009), with estimates varying due to sampling strategies (e.g., street vs. shelter youth, urban vs. rural), age of participants, and differences in definitions (i.e., whether the definition is restricted to the exchange of sex for money or includes exchange for food, a place to stay, or drugs). Though engagement in survival sex is not limited to youth that are homeless, there are no credible or supported estimates of the size of the problem in the general youth population (Stransky & Finkelhor, 2008). There are significant health risks associated with involvement in survival sex including exposure to sexually transmitted infections (STI’s), exposure to HIV, involvement in serious drug use (including injection drug use), increased risk of pregnancy, and victimization through sexual and physical assault (Ferguson et al., 2011; Greene et al., 1999; Halcon & Lifson, 2004; Tyler & Johnson, 2006; Whitbeck, Hoyt, Yoder, Cauce, & Paradise, 2001). In addition, researchers have demonstrated that engaging in illicit survival behaviors may exclude young people from the labor market and force them further into the underground street economy, especially if they are arrested and convicted (Ferguson et al., 2011), and failure to help homeless young people acquire job skills and find employment opportunities as they enter into adulthood places them at risk for chronic homelessness (Tyler & Johnson, 2006). Previous studies have identified multiple factors associated with survival sex participation among homeless youth including physical and sexual maltreatment (Greene et al., 1999; Whitbeck et al., 2001); drug use (Whitbeck et al., 2001), particularly heavy drinking and injection drug use (Halcon & Lifson, 2004); suicide attempts (Greene et al., 1999); length of time on the street, with recent runaway and shelter-using youth showing less involvement than street dependent youth (Greene et al., 1999); affiliation with peers involved in other illicit survival strategies (Whitbeck et al., 2001); participation in other types of non-sexual deviant subsistence strategies (Whitbeck et al., 2001); and coercion or pressure from friends or partners (Tyler & Johnson, 2006); perception of continued social support from home and older age at first run were negatively associated with survival sex (Whitbeck et al., 2001). A previous study of runaway adolescent females’ involvement in survival sex found that it was running away that put them at risk for survival sex, not a prior history of child sexual abuse (Seng, 1989). The only prospective analysis of entry into survival sex among homeless young women did not show a history of child sexual abuse to be an independent predictor of initiation (Weber, Boivin, Blais, Haley, & Roy, 2004); in this study, injection drug use, frequent drug use (more than two times/ week), use of heroin, PCP, and acid, and having a female sexual partner were predictive of involvement. The question still arises whether homeless young women become involved in survival sex primarily as a consequence of previous traumatic events and experiences, or as a response to the exigencies of homelessness and the particularly desperate circumstances they confront. Despite the prevalence of survival sex among this young and highly vulnerable population and the obvious potential for grave and negative outcomes, there is surprisingly little research on homeless young women’s involvement. This study characterizes the early experiences of a cohort of homeless young women with a history of involvement in survival sex and compares them to the experiences of homeless young women who had not been involved, and describes influences on and circumstances of initial involvement for those engaged, in an effort to better understand the pathways into participation. The findings from this study may be useful in shaping effective interventions for decreasing initiation of and participation in survival sex by homeless young women. Method Participants Homeless young women, ages 18–24, seeking medical care at designated service sites for homeless youth in the East Hollywood area of Los Angeles, California were recruited to participate in this study. Service sites included an established clinic for homeless and at-risk youth and as well as five homeless youth-specific agencies providing drop-in center services, shelter, and/or transitional living. Young women were screened by one of the regular health care team staff (case manager, nurse practitioner, or physician) for involvement in survival sex as part of the routine psychosocial assessment process. Medical services were provided by the same team at all of the sites. All young women (18–24) who were homeless (i.e., reported living in a shelter, transitional living program, park, street, abandoned building, motel, or doubling up/couch-surfing with friends) and reported any current or past involvement in survival sex (described as exchanging sex for food, drugs, money or a place to stay), were asked by the person doing the assessment if they were interested in learning more about a research study. If they indicated they were, they were connected with a trained research assistant to complete the consent and enrollment process. Thirty (30) homeless young women seeking medical services at the same sites who did not disclose survival sex but met the other study criteria were recruited in the same manner to serve as a comparison group. None of the identified young women declined to be surveyed. Survey administration Consent was obtained by a research assistant, and young women were surveyed utilizing an Audio Computer Assisted SelfInterview (ACASI). The research assistant was present throughout the process to answer questions if needed; all surveys were
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completed in private spaces in the clinic and agencies. Any young woman requesting help or asking to speak with someone after they completed the survey was referred back to the health care team for assistance. The ACASI method allowed subjects to be interviewed without the face-to-face sharing of any information, enhancing the privacy and confidentiality of subjects and removing barriers to honest responses, such as embarrassment, feedback from facial expressions of the interviewer, and other social influences (Gribble, Miller, Rogers, & Turner, 1999; Kalichman, 1998). Since questions were audible to the subjects through earphones, the effect of participants’ literacy levels on comprehension was minimized. The survey usually took about 30 min to complete. After the surveys were conducted and the data were reviewed, it was found that six of the young women who had denied involvement in survival sex in the initial screening disclosed involvement when asked in the survey. In the end, 36 young women involved in survival sex and 24 young women who were not involved were surveyed. Surveys were completed during 2006–2008. In compensation for their time, study participants were provided a fast food gift card valued at $15.00 upon completion of the survey. The study was approved by the Institutional Review Board of Children’s Hospital Los Angeles. Survey instrument A survey was developed specifically for this study by investigators with extensive clinical and research experience with homeless youth. In constructing the survey, investigators reviewed previous studies with homeless youth and where appropriate, selected questions that had previously been used to capture sociodemographic characteristics, background information and data on risk behaviors. The survey consisted of 76 questions covering demographics (including educational level, number of children), sexual orientation, current housing or shelter status and length of time homeless, children’s current living arrangements, and several questions on sexual health, including history of known sexually transmitted infections (STIs) and history of HIV testing and results. Every question in the survey offered a response of “Don’t Know,” “Refuse to Answer,” and “Not Applicable.” In addition, the survey included questions in the following domains. Abuse The survey included questions on experiences with physical and sexual child abuse – physical abused was defined as a positive response to the question “when you were growing up did either of your parents or guardians, or any other adults, ever hit you so hard that it left bruises or other injuries?” Sexual abuse was defined as a positive answer to the question: “Did either of your parents or guardians, or any other adult ever sexually abuse you? (By sexual abuse, I mean things like masturbating in front of you, touching you in a sexual way, forcing you to touch their body in a sexual way, or having sex with them.”). System involvement The survey included questions regarding history of involvement in the dependency, juvenile delinquency, and adult correctional systems. Mental health and substance use Young women were also asked about a history of psychiatric hospital admissions, use of psychotropic medications, and history of attempted suicide. History of attempted suicide was defined as a positive response to the question: “Have you ever tried to kill yourself?”. They were also asked about injection drug use. Survival sex Survival sex was defined as the exchange of sex for food, drugs, money or a place to stay. Respondents who indicated a history of survival sex were asked a series of questions about their experiences: age at first exchange, living arrangement at first exchange, what they had exchanged sex for (money, a place to stay, drugs, food, other), contraceptive use during survival sex, influences on involvement, coercion, use of drugs during their first encounter and most recent encounter, involvement with a pimp, number of sexual partners, violence experienced while engaging in survival sex (i.e., battery, injury, robbery, sexual assault), and whether they had ever been arrested for survival sex, as well as reasons for discontinuing involvement if they had stopped (i.e., didn’t like the way it made me feel, too dangerous, boyfriend/girlfriend made me stop, stopped using drugs, spirituality/religion, arrest). There were also two open-ended questions to try to better understand young women’s experiences: “How did you get involved in survival sex?” and “Thinking back, what do you feel about your experiences of being involved in survival sex?” Young women typed their responses to these questions into the computer during survey administration. Data analysis SPSS v.16 was the statistical programming package used for all analyses. Independent sample t-tests, Pearson chi-square tests, and Fisher’s Exact Test (when cell sizes were less than 5) were used to identify statistically significant differences between those who had engaged in survival sex and those who had not. Responses that were missing, refused, or unknown, or otherwise skipped were removed from the respective analyses. Statistical significance was set at p 0.05.
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The open-ended responses in the survey were read by the first and second authors, who independently identified emergent themes within answers to each of the two open-ended questions. Given the field of all answers to a question, thematic categories were created at a sufficiently abstract level jointly by the two investigators to allow conceptually related answers to be grouped within the category, while at the same time creating categories that were maximally distinct from one another (Glaser, 1992). The resultant categories were seen by authors to capture dimensions that underlie the variations in the patterns of answers given by respondents. Inter-rater reliability was over 0.85. The fourth author reconciled the category of “desperation” into the category of basic needs, thus boosting the inter-rater reliability above 0.90. Reliability for coding of answers to the second question was similarly high. Any instances of disagreement were reconciled through discussion. Results The young women involved in survival sex were not significantly different in racial/ethnic composition compared to young women not involved in survival sex: 28% vs. 21% African American, 22% vs. 25% Latino, 33% vs. 29% white and 17% vs. 25% multi-ethnic. The general population of the community in which the survey was conducted, Metro Service Planning Area 4 of Los Angeles County, is remarkably different, with 5.9% African American, 54.2% Latino, 21.9% white and 15.3% Asian (Children’s Planning Council of Los Angeles, 2005) – see Table 1. There were no significant differences between young women who disclosed survival sex and those who did not in terms of their level of education, sexual orientation or having had a teenage mother. However, the mothers of those involved in survival sex were on average younger than the mothers of those not involved (21.3 years vs. 25.8 years; t ¼ 2.03; df ¼ 32.9; p < 0.05 – see Table 1). Rates of pregnancy and childbearing were similar between both survey groups. Most of the surveyed young women had been pregnant (66.7% for those involved in survival sex and 78.3% for those not involved). Fifty-four percent (n ¼ 13) of the survival sex engaged group had children and 72% (n ¼ 13) of the comparison group had children. Many of the young women Table 1 Demographic and homeless characteristics by involvement in survival sex. Frequency (percentage)
Mean age (Mean, SD)a Ethnicity Los Angeles County SPA Estimates*** African American 5.9 White 21.9 Hispanic 54.2 Other/multiethnic 15.3 Sexual orientationb Straight Bisexual Lesbian/questioning Mean maternal age at respondents’ birtha High school graduate Ward of the court or state (ever) Involvement youth or adult correctional system (ever) Length of time homeless Three months Three to six months Six to twelve months Over 12 months Ever pregnant Number of children (n ¼ 42) None One Two Three Four Child living arrangements (n ¼ 25) Self With other family Foster care Don’t know Ever injected drugs Ever had a sexually transmitted infection a
Involved in survival sex (n ¼ 36)
Not involved in survival sex (n ¼ 24)
Total sample (n ¼ 60)
21.08 2.14**
20.08 1.72
20.68 2.03
10 (27.8) 12 (33.3) 8 (22.2) 6 (1.7)
5 7 6 6
15 19 14 12
12 (33.3) 20 (55.6) 4 (11.1) (n ¼ 30) 21.33 5.31 20 (55.6) 17 (47.2) 18 (50.0) (n ¼ 24) 6 (25.0) 7 (29.2) 3 (12.5) 8 (33.3) (n ¼ 36) 24 (66.7)
12 (50.0) 9 (37.5) 3 (12.5) (n ¼ 21) 25.81 7.73* 13 (54.2) 11 (45.8) 10 (41.7) (n ¼ 16) 4 (25.0) 2 (12.5) 5 (31.2) 5 (31.2) (n ¼ 23) 18 (78.3)
24 (40.0) 29 (48.3) 7 (11.7) (n ¼ 51) 23.18 6.72 33 (55.0) 28 (46.7) 28 (46.7) (n ¼ 40) 10 (25.0) 9 (22.5) 8 (20.0) 13 (32.5) (n ¼ 59) 42 (71.2)
11 (45.8) 4 (16.7) 6 (25.0) 2 (8.3) 1 (4.2)
5 8 5 0 0
(27.8) (44.4) (27.8) (0.0) (0.0)
16 (26.7) 12 (20.0) 11 (18.3) 2 (3.3) 1 (1.7)
6 (50.0) 3 (25.0) 2 (16.7) 1 (8.3) 6 (16.7) 11 (30.0)
8 4 1 0 3 3
(61.5) (30.8) (7.7) (0.0) (12.5) (12.5)**
14 (56.0) 7 (11.7) 3 (5.0) 1 (1.7) 9 (15.0) 14 (23.3)
(20.8) (29.2) (25.0) (25.0)
(25.0) (31.7) (23.3) (20.0)
Denotes use of t-test. Denotes use of Pearson chi-square p-value. Else, one-sided p-value from Fisher’s Exact Test.*Statistical significance is identified as having a p-value less than 0.05. **Marginal statistical significance is identified as having a p-value greater than 0.05 but less than 0.10. ***Children’s Planning Council 2005. b
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had multiple children, including 69.2% of the homeless young women involved in survival sex and 38.5% of the uninvolved young women (see Table 1). The majority of young women had had their children living with them regardless of whether they were involved in survival sex (50% for those involved and 61.5% for those not involved); many children were living with other family members and some were in foster care (see Table 1). The 2 groups had differing rates of physical abuse which were marginally significant (c2(1) ¼ 2.99, p < 0.10; effect size ¼ 0.23) – 77.8% for those with involvement in survival sex and 56.5% for those with no involvement, though frequency of abuse was similar between the two groups (see Table 2). Homeless young women experienced physical abuse both as young children and as adolescents. The majority of young women (80% for those in survival sex and over 90% not involved) experienced physical abuse before the age of 12, and more than 45% of involved young women and over 60% of others experienced physical abuse after age 12. Rates were similar between the two groups for age of abuse and being removed from the home because of physical abuse (see Table 2). Similarly, rates of childhood sexual abuse were high and not significantly different for both groups of homeless young women (41.7% for those involved and 30.4% for those not involved). Age of abuse, and whether the abuse occurred once or twice or persisted over a year; location (at home or in foster care) abuser (parent, stepparent, mother’s boyfriend, other family member or other caregiver) and whether it resulted in removal from home showed no statistical difference between the groups (see Table 2). Both groups of homeless young women had similar rates of involvement in foster care and juvenile justice placement (see Table 1). Rates of having been in a psychiatric hospital were high and identical for both groups of young women (41.7%) – see Table 3. For both groups, among those that had been in a psychiatric hospital, most had been hospitalized on more than three occasions and for over a week (see Table 3). Rates of attempted suicide were significantly higher for young women involved in survival sex; (61.1% vs. 25.0%, c2(1) ¼ 7.55, p < 0.01, effect size ¼ 0.34). Mean age and number of attempts were similar (Table 3). Over a quarter of young women (27%) involved in survival sex attempted suicide after initiation. History of sexually transmitted infections (STI’s) was marginally significant (c2(1) ¼ 2.62, p < 0.10, effect size ¼ 0.21) between the two survey groups; history of injection drug use was similar (see Table 1). None of the young women disclosed that they were HIV positive. Experiences of homeless young women involved in survival sex Among those young women who had been involved in survival sex, the median age of first survival sex encounter was 16 with an age range of 11–23. Over half of the young women (58.3%) first engaged in survival sex as minors. 8.3% were 11–12 Table 2 Childhood physical and sexual abuse by involvement in survival sex. Frequency (percentage)
Physical abuse History of physical abuse Under age 12 (n ¼ 41) Over age 12 (n ¼ 41) Physically abused at home (n ¼ 41) Physically abused in foster care (n ¼ 41) Frequent physical abuse (n ¼ 41) One or two times More than 1 or 2 times Abuse-related removal from home (n ¼ 41) Sexual abuse History of sexual abuse Abused under age 10 (n ¼ 22) Abused age 10 to 14 (n ¼ 22) Abused 15 years or over (n ¼ 22) Frequency of sexual abuse One or two times only Less than one year More than one year Who abused you? Parent Stepparent Mother’s boyfriend Other caregiver Other family member Sexually abused at home (n ¼ 21) Sexually abused in foster care (n ¼ 21) Abuse-related removal from home (n ¼ 23)
Involved in survival sex
Not involved in survival sex
Total sample
(n ¼ 36) 28 (77.8) 23 (82.1) 13 (46.4) 23 (82.1) 4 (14.3)
(n ¼ 23) 13 (56.5)** 12 (92.3) 8 (61.5) 13 (100.0) 2 (15.4)
n ¼ 59 41 (68.3) 35 (58.3) 21 (35.0) 36 (60.0) 6 (10.0)
1 (3.6) 27 (96.4) 11 (39.3) (n ¼ 36) 15 (41.7) 12 (80.0) 4 (26.7) 1 (6.7) (n ¼ 14) 5(35.7) 1(7.1) 8(57.1) (n ¼ 13) 2(14.3) 2(14.3) 3 (21.4) 3 (21.4) 3(21.4) 8 (57.1) 1 (7.1) 6 (40.0)
0 (0) 13 (100.0) 4 (30.8) (n ¼ 23) 7 (30.4) 5 (71.4) 2 (28.6) 1 (14.3) (n ¼ 7) 3(42.9) 1(14.3) 3(42.9) (n ¼ 6) 1(14.3) 0 (0) 1(14.3) 1(14.3) 3(42.9) 4 (57.1) 1 (14.3) 2 (25.0)
1 (2.4) 40 (97.5) 6 (10.0) (n ¼ 59) 22 (36.7) 17 (77.3) 6 (27.3) 2 (9.1) (n ¼ 21) 8(38.1) 2(9.5) 11(52.4) (n ¼ 19) 3(14.3) 2(9.5) 4(19.0) 4(19.0) 6(28.6) 12 (57.1) 2 (9.5) 8 (34.8)
*Statistical significance is identified as having a p-value less than 0.05. **Marginal statistical significance is identified as having a p-value greater than 0.05 but less than 0.10.
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Table 3 Psychiatric hospitalization and suicide attempts by involvement in survival sex. Frequency (percentage)
Ever admitted to a psychiatric hospital Three or more admissions Ever attempted suicide Mean age at first suicide attempt Number of attempts One of two attempts More than 2 attempts Attempt after initiation of survival sex
Involved in survival sex (n ¼ 36)
Not involved in survival sex (n ¼ 24)
Total sample (n ¼ 60)
15 (41.7) 29 (80.6) 22 (61.1) 14.5 3.52
10 (41.7) 15 (62.5) 6 (25.0)* 14.14 2.17
25 (41.7) 44 (73.3) 28 (46.7) 14.21 3.25
13 (59.1) 9 (40.9) 6 (27)
3(50) 3(50) N/A
16(57.1) 12(42.9)
*Statistical significance is identified as having a p-value less than 0.05.
years old at the time of first exchange. Two-thirds of young women (66.7%) were homeless at the time of initial involvement, although 16.7%were living with parents, 11.1% were living with friends or on their own, and 5.5% were in foster care (Table 4). Fifteen (41.7%) of the young women were introduced into their first survival sex encounter by someone already involved in survival sex – two (13.3%) reported a family member was responsible and thirteen (86.6%) reported a friend. Of the thirteen young women that reported a friend was responsible, nearly half (6) met the person while homeless on the street, one met the person in a shelter, three met the person at school, and one met the person through her family. Nearly a fifth of the young women (19.4%) were forced or threatened at their first survival sex encounter and a third (33.3%) were using drugs at the time of their first encounter (Table 4). The majority of young women (63.9%) used contraception while involved in survival sex. The most common reasons young women selected for engaging in survival sex were related to meeting basic needs. Most (82.9%) indicated that they had exchanged sex for money, but well over half (62.9%) indicated they had exchanged sex for a place to stay and a quarter (25.7%) indicated they had exchanged sex for food. Over one-fifth (22.9) indicated they had exchanged sex for drugs, and 6.2% indicated they had exchanged sex for other reasons, in one case, “to take care of my son.” Table 4 Circumstances of initiation and characteristics of survival sex experiences (n ¼ 36). Frequency (percent) Age at first survival sex encounter 11–12 13–15 16–17 18–23 Living situation at time of first sex exchange encounter Parent Foster care Friend or alone Homeless Characteristics of first survival sex encounter Drug or alcohol use at time of encounter Forced or threatened Introduced to survival sex by someone already involved Family member (n ¼ 15) Same age or younger friend (n ¼ 15) Older friend (n ¼ 15) Had someone who found customers and took care of the money Sex was exchanged for Money Place to stay Drugs Food Something else Time of last sex exchange encounter Less than one month Three months or less Three to six month Six to twelve months 12 months or more Experiences while engaged in survival sex Sexually assaulted Battered, beaten, or injured Robbed Arrested Use birth control consistently while engaged in survival sex
3 9 9 15
(8.3) (25.0) (25.0) (41.7)
6 2 4 24
(16.7) (5.5) (11.1) (66.7)
12 7 15 2 5 8 7
(33.3) (19.4) (41.7) (13.3) (33.3) (53.4) (19.4)
29 22 8 9 3
(82.9) (62.9) (22.9) (25.7) (6.2)
10 4 4 5 13
(27.8) (11.1) (11.1) (13.9) (36.1)
14 13 16 11 23
(38.9) (36.1) (44.4) (30.6) (63.9)
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Seven of the young women (19.4%) indicated they utilized what was effectively a pimp who procured customers and took care of the money (see Table 4). Many of the young women were victims of crime while engaging in survival sex: 44.4% reported being robbed, 38.9% were sexually assaulted and 36.1% were battered or beaten. Nearly a third (30.6%) were arrested for prostitution while engaged in survival sex (see Table 4). Over a quarter (27.8%) of young women had engaged in survival sex in the last month; over a third (38.9%) had participated within the last three months; and a half of the young women had engaged in survival sex in the last six months. Over a third (36.1%) of young women had not exchanged sex for a year or more (Table 4). Of those reporting survival sex in the last month (n ¼ 10), seven of the young women disclosed that they had 1 to 2 customers, two had 5 to 10, and one reported more than 10. Among young women who had not been involved in survival sex for over a month, 13 (50%) stopped because “I didn’t like the way it made me feel,” six (25%) because “it was too dangerous,” two (10%) because their boyfriend or girlfriend wanted them to stop, one each because of stopping using drugs and religion/spirituality and three who cited other reasons but did not specify them. Responses to the open-ended questions further convey the experiences of young women involved in survival sex. In response to the question “How did you get involved in survival sex?” (92%) provided a response, about half of which (16) were one or two words answers; the other responses were longer phrases or sentences, half of which (8) provided more than one reason for involvement. Four core themes emerged from the data to help understand young women’s involvement – desperate for essentials/meeting basic needs; friends/peer influences/social norms; coercion; and drugs. By far, the predominant reason (cited by well over half the respondents) was for meeting basic needs – a place to stay, food, or money – with needing a place to stay the most commonly identified reason. Their desperation was evident. One young woman wrote: “I needed to eat because I hadn’t eaten all day and I am pregnant;” another wrote “I was homeless and needed a place to stay and food;” and another, “I had no where to go and I was desperate.” The influence of friends, peers, and social norms emerged as a compelling reason for a third of the young women. One young woman wrote: “Someone told me it was the right thing to do.” Another wrote: “I saw people I knew doing it and thought it wasn’t so bad;” and another said: “I met a girl in Hollywood that introduced me to that lifestyle.” Over 10% of the young women indicated that they had been coerced into survival sex – one of them wrote “I was kidnapped by a pimp who forced me to prostitute myself;” another said: “this guy made me do it, and if I didn’t he would beat me up but I never wanted to do it willingly.” Over 10% of the young women indicated they had exchanged sex as a way to get drugs: “the first time the guy was the drug dealer. He had more, and I needed more. He liked me. So after him and I talked, we agreed he would give me a certain amount and I would have sex with him. So it was all about drugs – never for a place to stay.” The second open ended question was “Thinking back, what are your feelings about your experiences of being involved in survival sex?” As to be expected, the predominant theme that emerged was one of regret and shame (15/36 responses). As one young woman said: “It makes me disgusted that I had to sink so low to be able to keep myself off the streets.” Another stated: “I feel as if I lowered myself by selling my body – it made me feel like I was a bad person;” one young woman said “I feel like a nobody - it was the worst thing I’ve ever done in my life;” and one young woman said: “I would never do it again. I did it recently for money and never got paid. I even had a boyfriend at the time. I just felt terrible inside, like I had let myself down. When I did it for drugs looking back it just makes me sad.” A few of the young women seemed to be able to accept their involvement without the same intense feelings of regret – one young woman stated: “I really don’t like the fact that I did it but it’s nothing I can change;” another responded “I feel that I made a bad decision about doing it and should have never done it;” and one young woman stated: “I learned something.” Discussion What is most striking about the findings from this study is the similarity between homeless young women involved in survival sex and those not involved. There was no evidence of differences in age, educational level, ethnicity, or sexual orientation that would distinguish homeless young females who had been involved in survival sex from those that had not been involved. The homeless young women, whether involved or uninvolved in survival sex, had similarly high rates of childhood sexual abuse, dependency system involvement, juvenile and adult incarceration, and psychiatric hospitalization, consistent with other studies of homeless young people (Robertson & Toro, 1999; Toro et al., 2007). Both groups of young women were similar in the length of time they had been homeless, pregnancy history, childbearing, and prevalence of injection drug use. The findings from this study confirm that homeless young women represent a particularly traumatized, high-risk population, but most of the socio-demographic characteristics and background experiences we investigated do not help explain why some young women became involved in survival sex while others do not. This study did find marginally significantly higher rates of childhood physical abuse among homeless young women involved in survival sex, consistent with other studies (Bell & Walls, 2011; Greene et al., 1999; Whitbeck, 2009; Whitbeck et al., 2001), although we did not find childhood sexual abuse to be a risk factor for involvement, in contrast to other research (Whitbeck et al., 2001). Despite this, our findings regarding the initiation of survival sex before leaving home (22% of young women involved in survival sex reported that their first survival sex encounter occurred when they were living with a parent or in foster care, with 8.3% of young women initiating survival sex between the ages of 11–12) highlight concern about the impact of home environments and caregiver behavior on survival sex participation. The prevalence of having had a sexually transmitted infection was marginally significant between the two groups of young women, with those involved in
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survival sex more likely to report a sexually transmitted infection, consistent with findings from other studies (Greene et al., 1999). We found that young women involved in survival sex were significantly more likely to report a suicide attempt than those not involved in survival sex. Previous studies have shown that suicide attempts are associated with increased survival sex participation among homeless youth (Bell & Walls, 2011; Greene et al., 1999; Whitbeck, 2009). In our study, 73% of homeless young women involved in survival sex who had attempted suicide, made their first attempt prior to initiation, suggesting that either prior suicide attempts are a risk factor for survival sex or that the factors that make them vulnerable to suicide also make them vulnerable to survival sex. Consistent with other studies, our findings suggest that economic necessity, involvement with peers involved in survival sex, drug involvement, and coercion contribute to survival sex participation for homeless young women. The primary reason given by young women in both the close-ended and open-ended questions suggest that the challenges inherent in homelessness and the necessity of meeting basic needs (a place to stay, food, money) were key factors contributing to their participation. Other studies have identified that desperate circumstances and a lack of alternatives for meeting economic needs drive homeless young people into survival sex and other illicit or “non-conventional” survival strategies (Bell & Walls, 2011; Cusick, 2002; Ferguson et al., 2011; Greene et al., 1999; Tyler & Johnson, 2006). The social influence of peers emerged as a contributing factor to survival sex participation for the homeless young women in our study, second only to the drive to meet material needs. While associations with other street-involved peers is a known influence on survival sex participation (Cusick, 2002; Ferguson et al., 2011; Whitbeck et al., 2001), our study specifically investigated whether initiation into survival sex occurred due to the influence of a friend or family member. The increased suicide risk for homeless young women involved in survival sex found in our study, along with the high rates of victimization experienced by the young women while engaging in survival sex, and the regret and shame articulated by the young women involved, compel us to identify effective interventions to prevent and end young women’s participation in survival sex. The principal limitations of this study are convenience sampling strategies and limited power due to low sample size. Survey respondents were identified at service sites for homeless youth; given that there are differences between youth who access services and youth who do not (Bell & Walls, 2011; Ferguson et al., 2011), there is limited generalizability of the present findings. It seems reasonable to believe that those youth that do not access services might demonstrate a higher risk profile. Additional limitations may be due to recall bias and reluctance to report very personal and sensitive questions, despite the use of an ACASI survey. Given this situation, it is likely that there was an underreporting of much of the information. Future research should: 1) survey a larger population to ascertain if the similarity of the two groups is due to the low power of this study; 2) survey homeless young women who do not access services to assure a more representative sample of young women engaged in survival sex; and 3) continue efforts to identify factors that put specific young women at higher risk for involvement in survival sex as well as protective factors that might mitigate against participation. Findings from the study can help elucidate effective programmatic and policy responses to survival sex involvement among homeless young women. This study implies that efforts to prevent survival sex among young women and protect them from the grave consequences of involvement, may best be directed at providing the supports that can ameliorate those conditions that lead to homelessness. It also implies that, similar to the conclusions of other studies (Bell & Walls, 2011; Ferguson et al., 2011; Greene et al., 1999), youth who are homeless and without a supportive family to return to, need realistic alternatives to survival sex to meet basic material and economic needs. While there’s a critical need for programs directed at reducing risk behaviors among homeless young women, especially suicide prevention interventions, we need to ensure that our services are designed to support young people’s safety, stability and self-sufficiency. We need to strengthen our housing programs for homeless youth and invest in educational and employment training programs that can safeguard their futures and offer them a pathway out of homelessness. References Bell, S., & Walls, N. (2011). Correlates of engaging in survival sex among homeless youth and young adults. The Journal of Sex Research, 48(5), 423. Cusick, L. (2002). Youth prostitution: a literature review. Child Abuse Review, 11, 230–251. Ferguson, K., Bender, K., Thompson, S., Xie, B., & Pollio, D. (2011). Correlates of street-survival behaviors in homeless young adults in four U.S. cities. American Journal of Orthopsychiatry, 81(3), 401–409. Glaser, B. G. (1992). Basics of grounded theory analysis: Emergence vs forcing. Mill Valley, CA: Sociology Press. Greene, J., Ennett, S., & Ringwalt, C. (1999). Prevalence and correlates of survival sex among runaway and homeless youth. American Journal of Public Health, 89(9), 1406–1409. Gribble, J., Miller, H., Rogers, S., & Turner, C. (1999). Interview mode and measurement of sexual behaviors: methodological issues. Journal of Sex Research, 36, 16–24. Halcon, L., & Lifson, A. (2004). Prevalence and predictors of sexual risks among homeless youth. Journal of Youth and Adolescence, 33(1), 71–80. Hammer, H., Finkelhor, D., & Sedlak, A. (2002). Runaway/thrownaway children: national estimates and characteristics. Office of Juvenile Justice and Delinquency Prevention. Retrieved from https://www.ncjrs.gov/html/ojjdp/nismart/04/index.html Accessed 13.08.13. Kalichman, S. (1998). Preventing AIDS: A sourcebook for behavioral interventions. Mahwah, NJ: Lawrence Erlbaum Associates. National Alliance to End Homelessness. (2009). Homeless youth and sexual exploitation: Research findings and practice implications. http://www. endhomelessness.org/library/entry/homeless-youth-and-sexual-exploitation-research-findings-and-practice-impli Accessed 13.08.13. Robertson, M., & Toro, P. (1999). Homeless youth: research, intervention and policy. In Fosburg, & Dennis (Eds.), Practical lessons: The 1998 national symposium on homelessness research. Washington DC: US Department of Housing and Urban Development and U.S. Department of Health and Human Services. Seng, M. (1989). Child sexual abuse and adolescent prostitution: a comparative analysis. Journal of Adolescence, 24(95), 665–675. Stransky, M., & Finkelhor, D. (2008). How many juveniles are involved in prostitution in the U.S.? Crimes Against Children Research Center. http://www.unh. edu/ccrc/prostitution/Juvenile_Prostitution_factsheet.pdf. Retrieved 11.08.13.
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Toro, P., Dworsky, A., & Fowler, P. (2007). Homeless youth in the United States: recent research findings and intervention approaches. In 2007 national symposium on homelessness research. Toro, P., Lesperance, T., & Braciszewski, J. (2011). Heterogeneity of homeless youth, from homeless brief #4, national alliance to end homelessness. Homelessness Research Institute. http://www.rhyttac.net/sites/default/files/research/the%20heterogeneity%20of%20homeless%20youth%20in%20america%20examin ing%20typologies.pdf Accessed 13.08.13. Tyler, K., & Johnson, K. A. (2006). Trading sex: voluntary or coerced? The experiences of homeless youth. Journal of Sex Research, 43(3), 208–216. Weber, A., Boivin, J.-F., Blais, L., Haley, N., & Roy, E. (2004). Predictors of initiation into prostitution among female street youths. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 81(4), 584–595. Whitbeck, L. (2009). Mental health and emerging adulthood among homeless young people. Psychology Press. Whitbeck, L., Hoyt, D., Yoder, K., Cauce, A., & Paradise, M. (2001). Deviant behavior and victimization among homeless and runaway adolescents. Sociology Department, Faculty Publications. Paper 94 http://digitalcommons.unl.edu/sociologyfacpub/94 Accessed 13.08.13.
Contents lists available at ScienceDirect
Journal of Adolescence journal homepage: www.elsevier.com/locate/jado
Coming of age on the streets: Survival sex among homeless young women in Hollywood Curren W. Warf a, b, *, Leslie F. Clark a, b, Mona Desai a, Susan J. Rabinovitz a, Golnaz Agahi a, Richard Calvo a, Jenny Hoffmann c a
Division of Adolescent Medicine, Children’s Hospital Los Angeles, USA Department of Pediatrics, Keck School of Medicine, University of Southern California, USA c School of Medicine, University of California San Diego, USA b
a b s t r a c t Keywords: Homeless youth Prostitution Survival sex Adolescent behavior Child abuse Sexual Homeless children
This study examined childhood physical or sexual abuse, involvement in dependency or delinquency systems, psychiatric hospitalization, and suicide as possible risk factors for survival sex among homeless young women. Homeless young women were found to have similarly high rates of childhood sexual abuse, dependency and delinquency systems involvement, and psychiatric hospitalization. Homeless young women involved in survival sex disclosed higher rates of attempted suicide and reported marginally higher rates of childhood physical abuse. Analysis of qualitative data showed that those engaged in survival sex were motivated primarily by desperation to meet basic needs including a place to stay, food and money, and one third mentioned that peers commonly were influential in decisions to engage in survival sex. Others were influenced by coercion (10%) or pursuit of drugs (10%). Young women engaged in survival sex generally experienced regret and shame about their experience. Ó 2013 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
It is estimated that in the United States over one million youth under age 18 are homeless each year, about half of whom are females (Hammer, Finkelhor, & Sedlak, 2002). Estimates of homeless young adults ages 18–24 in the United States range from 750,000 to 2 million (Whitbeck, 2009); samples of the young adult homeless youth population are disproportionately male (Toro, Dworsky, & Fowler, 2007). The numbers of homeless youth and their profiles differ depending on the source of the data, definitions of homelessness used, age ranges of youth surveyed, and sampling strategies and methods employed (Toro et al., 2007; Toro, Lesperance, & Braciszewski, 2011; Whitbeck, 2009). Homeless young people consistently identify conflict with their parents as the primary reason for their homelessness (Robertson & Toro, 1999) (Toro et al., 2007), and conflicts related to step-parent relationships, sexual activity, pregnancy, sexual orientation, school problems, and alcohol and drug use contribute to youth homelessness (Toro et al., 2007). In addition, homeless youth often cite physical or sexual abuse from parents or caregivers as their reason for leaving home (Toro et al., 2007; Whitbeck, 2009). Regardless of the cause, homeless youth confront the challenge of surviving without the support of parents and family, with a poor education and without marketable job skills. As a result, many homeless young people turn to strategies such as panhandling, shoplifting, stealing, dealing drugs, and prostitution or survival sex (i.e.,
* Corresponding author. Division of Adolescent Health and Medicine, Department of Pediatrics, British Columbia Children’s Hospital, CSB V2.223, 950 West 28th Ave., Vancouver, BC V6K 1B1, Canada. Tel.: þ1 604 875 2000x4635. E-mail address: [email protected] (C.W. Warf). 0140-1971/$ – see front matter Ó 2013 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.adolescence.2013.08.013
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participating in sexual acts in exchange for money, food, lodging, clothing, or drugs) in order to survive (Ferguson, Bender, Thompson, Xie, & Pollio, 2011; Greene, Ennett, & Ringwalt, 1999; Robertson & Toro, 1999; Tyler & Johnson, 2006; Whitbeck, 2009). Estimates range that from 10% to 50% of homeless youth become involved in survival sex (Greene et al., 1999; National Alliance to End Homelessness, 2009), with estimates varying due to sampling strategies (e.g., street vs. shelter youth, urban vs. rural), age of participants, and differences in definitions (i.e., whether the definition is restricted to the exchange of sex for money or includes exchange for food, a place to stay, or drugs). Though engagement in survival sex is not limited to youth that are homeless, there are no credible or supported estimates of the size of the problem in the general youth population (Stransky & Finkelhor, 2008). There are significant health risks associated with involvement in survival sex including exposure to sexually transmitted infections (STI’s), exposure to HIV, involvement in serious drug use (including injection drug use), increased risk of pregnancy, and victimization through sexual and physical assault (Ferguson et al., 2011; Greene et al., 1999; Halcon & Lifson, 2004; Tyler & Johnson, 2006; Whitbeck, Hoyt, Yoder, Cauce, & Paradise, 2001). In addition, researchers have demonstrated that engaging in illicit survival behaviors may exclude young people from the labor market and force them further into the underground street economy, especially if they are arrested and convicted (Ferguson et al., 2011), and failure to help homeless young people acquire job skills and find employment opportunities as they enter into adulthood places them at risk for chronic homelessness (Tyler & Johnson, 2006). Previous studies have identified multiple factors associated with survival sex participation among homeless youth including physical and sexual maltreatment (Greene et al., 1999; Whitbeck et al., 2001); drug use (Whitbeck et al., 2001), particularly heavy drinking and injection drug use (Halcon & Lifson, 2004); suicide attempts (Greene et al., 1999); length of time on the street, with recent runaway and shelter-using youth showing less involvement than street dependent youth (Greene et al., 1999); affiliation with peers involved in other illicit survival strategies (Whitbeck et al., 2001); participation in other types of non-sexual deviant subsistence strategies (Whitbeck et al., 2001); and coercion or pressure from friends or partners (Tyler & Johnson, 2006); perception of continued social support from home and older age at first run were negatively associated with survival sex (Whitbeck et al., 2001). A previous study of runaway adolescent females’ involvement in survival sex found that it was running away that put them at risk for survival sex, not a prior history of child sexual abuse (Seng, 1989). The only prospective analysis of entry into survival sex among homeless young women did not show a history of child sexual abuse to be an independent predictor of initiation (Weber, Boivin, Blais, Haley, & Roy, 2004); in this study, injection drug use, frequent drug use (more than two times/ week), use of heroin, PCP, and acid, and having a female sexual partner were predictive of involvement. The question still arises whether homeless young women become involved in survival sex primarily as a consequence of previous traumatic events and experiences, or as a response to the exigencies of homelessness and the particularly desperate circumstances they confront. Despite the prevalence of survival sex among this young and highly vulnerable population and the obvious potential for grave and negative outcomes, there is surprisingly little research on homeless young women’s involvement. This study characterizes the early experiences of a cohort of homeless young women with a history of involvement in survival sex and compares them to the experiences of homeless young women who had not been involved, and describes influences on and circumstances of initial involvement for those engaged, in an effort to better understand the pathways into participation. The findings from this study may be useful in shaping effective interventions for decreasing initiation of and participation in survival sex by homeless young women. Method Participants Homeless young women, ages 18–24, seeking medical care at designated service sites for homeless youth in the East Hollywood area of Los Angeles, California were recruited to participate in this study. Service sites included an established clinic for homeless and at-risk youth and as well as five homeless youth-specific agencies providing drop-in center services, shelter, and/or transitional living. Young women were screened by one of the regular health care team staff (case manager, nurse practitioner, or physician) for involvement in survival sex as part of the routine psychosocial assessment process. Medical services were provided by the same team at all of the sites. All young women (18–24) who were homeless (i.e., reported living in a shelter, transitional living program, park, street, abandoned building, motel, or doubling up/couch-surfing with friends) and reported any current or past involvement in survival sex (described as exchanging sex for food, drugs, money or a place to stay), were asked by the person doing the assessment if they were interested in learning more about a research study. If they indicated they were, they were connected with a trained research assistant to complete the consent and enrollment process. Thirty (30) homeless young women seeking medical services at the same sites who did not disclose survival sex but met the other study criteria were recruited in the same manner to serve as a comparison group. None of the identified young women declined to be surveyed. Survey administration Consent was obtained by a research assistant, and young women were surveyed utilizing an Audio Computer Assisted SelfInterview (ACASI). The research assistant was present throughout the process to answer questions if needed; all surveys were
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completed in private spaces in the clinic and agencies. Any young woman requesting help or asking to speak with someone after they completed the survey was referred back to the health care team for assistance. The ACASI method allowed subjects to be interviewed without the face-to-face sharing of any information, enhancing the privacy and confidentiality of subjects and removing barriers to honest responses, such as embarrassment, feedback from facial expressions of the interviewer, and other social influences (Gribble, Miller, Rogers, & Turner, 1999; Kalichman, 1998). Since questions were audible to the subjects through earphones, the effect of participants’ literacy levels on comprehension was minimized. The survey usually took about 30 min to complete. After the surveys were conducted and the data were reviewed, it was found that six of the young women who had denied involvement in survival sex in the initial screening disclosed involvement when asked in the survey. In the end, 36 young women involved in survival sex and 24 young women who were not involved were surveyed. Surveys were completed during 2006–2008. In compensation for their time, study participants were provided a fast food gift card valued at $15.00 upon completion of the survey. The study was approved by the Institutional Review Board of Children’s Hospital Los Angeles. Survey instrument A survey was developed specifically for this study by investigators with extensive clinical and research experience with homeless youth. In constructing the survey, investigators reviewed previous studies with homeless youth and where appropriate, selected questions that had previously been used to capture sociodemographic characteristics, background information and data on risk behaviors. The survey consisted of 76 questions covering demographics (including educational level, number of children), sexual orientation, current housing or shelter status and length of time homeless, children’s current living arrangements, and several questions on sexual health, including history of known sexually transmitted infections (STIs) and history of HIV testing and results. Every question in the survey offered a response of “Don’t Know,” “Refuse to Answer,” and “Not Applicable.” In addition, the survey included questions in the following domains. Abuse The survey included questions on experiences with physical and sexual child abuse – physical abused was defined as a positive response to the question “when you were growing up did either of your parents or guardians, or any other adults, ever hit you so hard that it left bruises or other injuries?” Sexual abuse was defined as a positive answer to the question: “Did either of your parents or guardians, or any other adult ever sexually abuse you? (By sexual abuse, I mean things like masturbating in front of you, touching you in a sexual way, forcing you to touch their body in a sexual way, or having sex with them.”). System involvement The survey included questions regarding history of involvement in the dependency, juvenile delinquency, and adult correctional systems. Mental health and substance use Young women were also asked about a history of psychiatric hospital admissions, use of psychotropic medications, and history of attempted suicide. History of attempted suicide was defined as a positive response to the question: “Have you ever tried to kill yourself?”. They were also asked about injection drug use. Survival sex Survival sex was defined as the exchange of sex for food, drugs, money or a place to stay. Respondents who indicated a history of survival sex were asked a series of questions about their experiences: age at first exchange, living arrangement at first exchange, what they had exchanged sex for (money, a place to stay, drugs, food, other), contraceptive use during survival sex, influences on involvement, coercion, use of drugs during their first encounter and most recent encounter, involvement with a pimp, number of sexual partners, violence experienced while engaging in survival sex (i.e., battery, injury, robbery, sexual assault), and whether they had ever been arrested for survival sex, as well as reasons for discontinuing involvement if they had stopped (i.e., didn’t like the way it made me feel, too dangerous, boyfriend/girlfriend made me stop, stopped using drugs, spirituality/religion, arrest). There were also two open-ended questions to try to better understand young women’s experiences: “How did you get involved in survival sex?” and “Thinking back, what do you feel about your experiences of being involved in survival sex?” Young women typed their responses to these questions into the computer during survey administration. Data analysis SPSS v.16 was the statistical programming package used for all analyses. Independent sample t-tests, Pearson chi-square tests, and Fisher’s Exact Test (when cell sizes were less than 5) were used to identify statistically significant differences between those who had engaged in survival sex and those who had not. Responses that were missing, refused, or unknown, or otherwise skipped were removed from the respective analyses. Statistical significance was set at p 0.05.
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The open-ended responses in the survey were read by the first and second authors, who independently identified emergent themes within answers to each of the two open-ended questions. Given the field of all answers to a question, thematic categories were created at a sufficiently abstract level jointly by the two investigators to allow conceptually related answers to be grouped within the category, while at the same time creating categories that were maximally distinct from one another (Glaser, 1992). The resultant categories were seen by authors to capture dimensions that underlie the variations in the patterns of answers given by respondents. Inter-rater reliability was over 0.85. The fourth author reconciled the category of “desperation” into the category of basic needs, thus boosting the inter-rater reliability above 0.90. Reliability for coding of answers to the second question was similarly high. Any instances of disagreement were reconciled through discussion. Results The young women involved in survival sex were not significantly different in racial/ethnic composition compared to young women not involved in survival sex: 28% vs. 21% African American, 22% vs. 25% Latino, 33% vs. 29% white and 17% vs. 25% multi-ethnic. The general population of the community in which the survey was conducted, Metro Service Planning Area 4 of Los Angeles County, is remarkably different, with 5.9% African American, 54.2% Latino, 21.9% white and 15.3% Asian (Children’s Planning Council of Los Angeles, 2005) – see Table 1. There were no significant differences between young women who disclosed survival sex and those who did not in terms of their level of education, sexual orientation or having had a teenage mother. However, the mothers of those involved in survival sex were on average younger than the mothers of those not involved (21.3 years vs. 25.8 years; t ¼ 2.03; df ¼ 32.9; p < 0.05 – see Table 1). Rates of pregnancy and childbearing were similar between both survey groups. Most of the surveyed young women had been pregnant (66.7% for those involved in survival sex and 78.3% for those not involved). Fifty-four percent (n ¼ 13) of the survival sex engaged group had children and 72% (n ¼ 13) of the comparison group had children. Many of the young women Table 1 Demographic and homeless characteristics by involvement in survival sex. Frequency (percentage)
Mean age (Mean, SD)a Ethnicity Los Angeles County SPA Estimates*** African American 5.9 White 21.9 Hispanic 54.2 Other/multiethnic 15.3 Sexual orientationb Straight Bisexual Lesbian/questioning Mean maternal age at respondents’ birtha High school graduate Ward of the court or state (ever) Involvement youth or adult correctional system (ever) Length of time homeless Three months Three to six months Six to twelve months Over 12 months Ever pregnant Number of children (n ¼ 42) None One Two Three Four Child living arrangements (n ¼ 25) Self With other family Foster care Don’t know Ever injected drugs Ever had a sexually transmitted infection a
Involved in survival sex (n ¼ 36)
Not involved in survival sex (n ¼ 24)
Total sample (n ¼ 60)
21.08 2.14**
20.08 1.72
20.68 2.03
10 (27.8) 12 (33.3) 8 (22.2) 6 (1.7)
5 7 6 6
15 19 14 12
12 (33.3) 20 (55.6) 4 (11.1) (n ¼ 30) 21.33 5.31 20 (55.6) 17 (47.2) 18 (50.0) (n ¼ 24) 6 (25.0) 7 (29.2) 3 (12.5) 8 (33.3) (n ¼ 36) 24 (66.7)
12 (50.0) 9 (37.5) 3 (12.5) (n ¼ 21) 25.81 7.73* 13 (54.2) 11 (45.8) 10 (41.7) (n ¼ 16) 4 (25.0) 2 (12.5) 5 (31.2) 5 (31.2) (n ¼ 23) 18 (78.3)
24 (40.0) 29 (48.3) 7 (11.7) (n ¼ 51) 23.18 6.72 33 (55.0) 28 (46.7) 28 (46.7) (n ¼ 40) 10 (25.0) 9 (22.5) 8 (20.0) 13 (32.5) (n ¼ 59) 42 (71.2)
11 (45.8) 4 (16.7) 6 (25.0) 2 (8.3) 1 (4.2)
5 8 5 0 0
(27.8) (44.4) (27.8) (0.0) (0.0)
16 (26.7) 12 (20.0) 11 (18.3) 2 (3.3) 1 (1.7)
6 (50.0) 3 (25.0) 2 (16.7) 1 (8.3) 6 (16.7) 11 (30.0)
8 4 1 0 3 3
(61.5) (30.8) (7.7) (0.0) (12.5) (12.5)**
14 (56.0) 7 (11.7) 3 (5.0) 1 (1.7) 9 (15.0) 14 (23.3)
(20.8) (29.2) (25.0) (25.0)
(25.0) (31.7) (23.3) (20.0)
Denotes use of t-test. Denotes use of Pearson chi-square p-value. Else, one-sided p-value from Fisher’s Exact Test.*Statistical significance is identified as having a p-value less than 0.05. **Marginal statistical significance is identified as having a p-value greater than 0.05 but less than 0.10. ***Children’s Planning Council 2005. b
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had multiple children, including 69.2% of the homeless young women involved in survival sex and 38.5% of the uninvolved young women (see Table 1). The majority of young women had had their children living with them regardless of whether they were involved in survival sex (50% for those involved and 61.5% for those not involved); many children were living with other family members and some were in foster care (see Table 1). The 2 groups had differing rates of physical abuse which were marginally significant (c2(1) ¼ 2.99, p < 0.10; effect size ¼ 0.23) – 77.8% for those with involvement in survival sex and 56.5% for those with no involvement, though frequency of abuse was similar between the two groups (see Table 2). Homeless young women experienced physical abuse both as young children and as adolescents. The majority of young women (80% for those in survival sex and over 90% not involved) experienced physical abuse before the age of 12, and more than 45% of involved young women and over 60% of others experienced physical abuse after age 12. Rates were similar between the two groups for age of abuse and being removed from the home because of physical abuse (see Table 2). Similarly, rates of childhood sexual abuse were high and not significantly different for both groups of homeless young women (41.7% for those involved and 30.4% for those not involved). Age of abuse, and whether the abuse occurred once or twice or persisted over a year; location (at home or in foster care) abuser (parent, stepparent, mother’s boyfriend, other family member or other caregiver) and whether it resulted in removal from home showed no statistical difference between the groups (see Table 2). Both groups of homeless young women had similar rates of involvement in foster care and juvenile justice placement (see Table 1). Rates of having been in a psychiatric hospital were high and identical for both groups of young women (41.7%) – see Table 3. For both groups, among those that had been in a psychiatric hospital, most had been hospitalized on more than three occasions and for over a week (see Table 3). Rates of attempted suicide were significantly higher for young women involved in survival sex; (61.1% vs. 25.0%, c2(1) ¼ 7.55, p < 0.01, effect size ¼ 0.34). Mean age and number of attempts were similar (Table 3). Over a quarter of young women (27%) involved in survival sex attempted suicide after initiation. History of sexually transmitted infections (STI’s) was marginally significant (c2(1) ¼ 2.62, p < 0.10, effect size ¼ 0.21) between the two survey groups; history of injection drug use was similar (see Table 1). None of the young women disclosed that they were HIV positive. Experiences of homeless young women involved in survival sex Among those young women who had been involved in survival sex, the median age of first survival sex encounter was 16 with an age range of 11–23. Over half of the young women (58.3%) first engaged in survival sex as minors. 8.3% were 11–12 Table 2 Childhood physical and sexual abuse by involvement in survival sex. Frequency (percentage)
Physical abuse History of physical abuse Under age 12 (n ¼ 41) Over age 12 (n ¼ 41) Physically abused at home (n ¼ 41) Physically abused in foster care (n ¼ 41) Frequent physical abuse (n ¼ 41) One or two times More than 1 or 2 times Abuse-related removal from home (n ¼ 41) Sexual abuse History of sexual abuse Abused under age 10 (n ¼ 22) Abused age 10 to 14 (n ¼ 22) Abused 15 years or over (n ¼ 22) Frequency of sexual abuse One or two times only Less than one year More than one year Who abused you? Parent Stepparent Mother’s boyfriend Other caregiver Other family member Sexually abused at home (n ¼ 21) Sexually abused in foster care (n ¼ 21) Abuse-related removal from home (n ¼ 23)
Involved in survival sex
Not involved in survival sex
Total sample
(n ¼ 36) 28 (77.8) 23 (82.1) 13 (46.4) 23 (82.1) 4 (14.3)
(n ¼ 23) 13 (56.5)** 12 (92.3) 8 (61.5) 13 (100.0) 2 (15.4)
n ¼ 59 41 (68.3) 35 (58.3) 21 (35.0) 36 (60.0) 6 (10.0)
1 (3.6) 27 (96.4) 11 (39.3) (n ¼ 36) 15 (41.7) 12 (80.0) 4 (26.7) 1 (6.7) (n ¼ 14) 5(35.7) 1(7.1) 8(57.1) (n ¼ 13) 2(14.3) 2(14.3) 3 (21.4) 3 (21.4) 3(21.4) 8 (57.1) 1 (7.1) 6 (40.0)
0 (0) 13 (100.0) 4 (30.8) (n ¼ 23) 7 (30.4) 5 (71.4) 2 (28.6) 1 (14.3) (n ¼ 7) 3(42.9) 1(14.3) 3(42.9) (n ¼ 6) 1(14.3) 0 (0) 1(14.3) 1(14.3) 3(42.9) 4 (57.1) 1 (14.3) 2 (25.0)
1 (2.4) 40 (97.5) 6 (10.0) (n ¼ 59) 22 (36.7) 17 (77.3) 6 (27.3) 2 (9.1) (n ¼ 21) 8(38.1) 2(9.5) 11(52.4) (n ¼ 19) 3(14.3) 2(9.5) 4(19.0) 4(19.0) 6(28.6) 12 (57.1) 2 (9.5) 8 (34.8)
*Statistical significance is identified as having a p-value less than 0.05. **Marginal statistical significance is identified as having a p-value greater than 0.05 but less than 0.10.
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Table 3 Psychiatric hospitalization and suicide attempts by involvement in survival sex. Frequency (percentage)
Ever admitted to a psychiatric hospital Three or more admissions Ever attempted suicide Mean age at first suicide attempt Number of attempts One of two attempts More than 2 attempts Attempt after initiation of survival sex
Involved in survival sex (n ¼ 36)
Not involved in survival sex (n ¼ 24)
Total sample (n ¼ 60)
15 (41.7) 29 (80.6) 22 (61.1) 14.5 3.52
10 (41.7) 15 (62.5) 6 (25.0)* 14.14 2.17
25 (41.7) 44 (73.3) 28 (46.7) 14.21 3.25
13 (59.1) 9 (40.9) 6 (27)
3(50) 3(50) N/A
16(57.1) 12(42.9)
*Statistical significance is identified as having a p-value less than 0.05.
years old at the time of first exchange. Two-thirds of young women (66.7%) were homeless at the time of initial involvement, although 16.7%were living with parents, 11.1% were living with friends or on their own, and 5.5% were in foster care (Table 4). Fifteen (41.7%) of the young women were introduced into their first survival sex encounter by someone already involved in survival sex – two (13.3%) reported a family member was responsible and thirteen (86.6%) reported a friend. Of the thirteen young women that reported a friend was responsible, nearly half (6) met the person while homeless on the street, one met the person in a shelter, three met the person at school, and one met the person through her family. Nearly a fifth of the young women (19.4%) were forced or threatened at their first survival sex encounter and a third (33.3%) were using drugs at the time of their first encounter (Table 4). The majority of young women (63.9%) used contraception while involved in survival sex. The most common reasons young women selected for engaging in survival sex were related to meeting basic needs. Most (82.9%) indicated that they had exchanged sex for money, but well over half (62.9%) indicated they had exchanged sex for a place to stay and a quarter (25.7%) indicated they had exchanged sex for food. Over one-fifth (22.9) indicated they had exchanged sex for drugs, and 6.2% indicated they had exchanged sex for other reasons, in one case, “to take care of my son.” Table 4 Circumstances of initiation and characteristics of survival sex experiences (n ¼ 36). Frequency (percent) Age at first survival sex encounter 11–12 13–15 16–17 18–23 Living situation at time of first sex exchange encounter Parent Foster care Friend or alone Homeless Characteristics of first survival sex encounter Drug or alcohol use at time of encounter Forced or threatened Introduced to survival sex by someone already involved Family member (n ¼ 15) Same age or younger friend (n ¼ 15) Older friend (n ¼ 15) Had someone who found customers and took care of the money Sex was exchanged for Money Place to stay Drugs Food Something else Time of last sex exchange encounter Less than one month Three months or less Three to six month Six to twelve months 12 months or more Experiences while engaged in survival sex Sexually assaulted Battered, beaten, or injured Robbed Arrested Use birth control consistently while engaged in survival sex
3 9 9 15
(8.3) (25.0) (25.0) (41.7)
6 2 4 24
(16.7) (5.5) (11.1) (66.7)
12 7 15 2 5 8 7
(33.3) (19.4) (41.7) (13.3) (33.3) (53.4) (19.4)
29 22 8 9 3
(82.9) (62.9) (22.9) (25.7) (6.2)
10 4 4 5 13
(27.8) (11.1) (11.1) (13.9) (36.1)
14 13 16 11 23
(38.9) (36.1) (44.4) (30.6) (63.9)
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Seven of the young women (19.4%) indicated they utilized what was effectively a pimp who procured customers and took care of the money (see Table 4). Many of the young women were victims of crime while engaging in survival sex: 44.4% reported being robbed, 38.9% were sexually assaulted and 36.1% were battered or beaten. Nearly a third (30.6%) were arrested for prostitution while engaged in survival sex (see Table 4). Over a quarter (27.8%) of young women had engaged in survival sex in the last month; over a third (38.9%) had participated within the last three months; and a half of the young women had engaged in survival sex in the last six months. Over a third (36.1%) of young women had not exchanged sex for a year or more (Table 4). Of those reporting survival sex in the last month (n ¼ 10), seven of the young women disclosed that they had 1 to 2 customers, two had 5 to 10, and one reported more than 10. Among young women who had not been involved in survival sex for over a month, 13 (50%) stopped because “I didn’t like the way it made me feel,” six (25%) because “it was too dangerous,” two (10%) because their boyfriend or girlfriend wanted them to stop, one each because of stopping using drugs and religion/spirituality and three who cited other reasons but did not specify them. Responses to the open-ended questions further convey the experiences of young women involved in survival sex. In response to the question “How did you get involved in survival sex?” (92%) provided a response, about half of which (16) were one or two words answers; the other responses were longer phrases or sentences, half of which (8) provided more than one reason for involvement. Four core themes emerged from the data to help understand young women’s involvement – desperate for essentials/meeting basic needs; friends/peer influences/social norms; coercion; and drugs. By far, the predominant reason (cited by well over half the respondents) was for meeting basic needs – a place to stay, food, or money – with needing a place to stay the most commonly identified reason. Their desperation was evident. One young woman wrote: “I needed to eat because I hadn’t eaten all day and I am pregnant;” another wrote “I was homeless and needed a place to stay and food;” and another, “I had no where to go and I was desperate.” The influence of friends, peers, and social norms emerged as a compelling reason for a third of the young women. One young woman wrote: “Someone told me it was the right thing to do.” Another wrote: “I saw people I knew doing it and thought it wasn’t so bad;” and another said: “I met a girl in Hollywood that introduced me to that lifestyle.” Over 10% of the young women indicated that they had been coerced into survival sex – one of them wrote “I was kidnapped by a pimp who forced me to prostitute myself;” another said: “this guy made me do it, and if I didn’t he would beat me up but I never wanted to do it willingly.” Over 10% of the young women indicated they had exchanged sex as a way to get drugs: “the first time the guy was the drug dealer. He had more, and I needed more. He liked me. So after him and I talked, we agreed he would give me a certain amount and I would have sex with him. So it was all about drugs – never for a place to stay.” The second open ended question was “Thinking back, what are your feelings about your experiences of being involved in survival sex?” As to be expected, the predominant theme that emerged was one of regret and shame (15/36 responses). As one young woman said: “It makes me disgusted that I had to sink so low to be able to keep myself off the streets.” Another stated: “I feel as if I lowered myself by selling my body – it made me feel like I was a bad person;” one young woman said “I feel like a nobody - it was the worst thing I’ve ever done in my life;” and one young woman said: “I would never do it again. I did it recently for money and never got paid. I even had a boyfriend at the time. I just felt terrible inside, like I had let myself down. When I did it for drugs looking back it just makes me sad.” A few of the young women seemed to be able to accept their involvement without the same intense feelings of regret – one young woman stated: “I really don’t like the fact that I did it but it’s nothing I can change;” another responded “I feel that I made a bad decision about doing it and should have never done it;” and one young woman stated: “I learned something.” Discussion What is most striking about the findings from this study is the similarity between homeless young women involved in survival sex and those not involved. There was no evidence of differences in age, educational level, ethnicity, or sexual orientation that would distinguish homeless young females who had been involved in survival sex from those that had not been involved. The homeless young women, whether involved or uninvolved in survival sex, had similarly high rates of childhood sexual abuse, dependency system involvement, juvenile and adult incarceration, and psychiatric hospitalization, consistent with other studies of homeless young people (Robertson & Toro, 1999; Toro et al., 2007). Both groups of young women were similar in the length of time they had been homeless, pregnancy history, childbearing, and prevalence of injection drug use. The findings from this study confirm that homeless young women represent a particularly traumatized, high-risk population, but most of the socio-demographic characteristics and background experiences we investigated do not help explain why some young women became involved in survival sex while others do not. This study did find marginally significantly higher rates of childhood physical abuse among homeless young women involved in survival sex, consistent with other studies (Bell & Walls, 2011; Greene et al., 1999; Whitbeck, 2009; Whitbeck et al., 2001), although we did not find childhood sexual abuse to be a risk factor for involvement, in contrast to other research (Whitbeck et al., 2001). Despite this, our findings regarding the initiation of survival sex before leaving home (22% of young women involved in survival sex reported that their first survival sex encounter occurred when they were living with a parent or in foster care, with 8.3% of young women initiating survival sex between the ages of 11–12) highlight concern about the impact of home environments and caregiver behavior on survival sex participation. The prevalence of having had a sexually transmitted infection was marginally significant between the two groups of young women, with those involved in
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survival sex more likely to report a sexually transmitted infection, consistent with findings from other studies (Greene et al., 1999). We found that young women involved in survival sex were significantly more likely to report a suicide attempt than those not involved in survival sex. Previous studies have shown that suicide attempts are associated with increased survival sex participation among homeless youth (Bell & Walls, 2011; Greene et al., 1999; Whitbeck, 2009). In our study, 73% of homeless young women involved in survival sex who had attempted suicide, made their first attempt prior to initiation, suggesting that either prior suicide attempts are a risk factor for survival sex or that the factors that make them vulnerable to suicide also make them vulnerable to survival sex. Consistent with other studies, our findings suggest that economic necessity, involvement with peers involved in survival sex, drug involvement, and coercion contribute to survival sex participation for homeless young women. The primary reason given by young women in both the close-ended and open-ended questions suggest that the challenges inherent in homelessness and the necessity of meeting basic needs (a place to stay, food, money) were key factors contributing to their participation. Other studies have identified that desperate circumstances and a lack of alternatives for meeting economic needs drive homeless young people into survival sex and other illicit or “non-conventional” survival strategies (Bell & Walls, 2011; Cusick, 2002; Ferguson et al., 2011; Greene et al., 1999; Tyler & Johnson, 2006). The social influence of peers emerged as a contributing factor to survival sex participation for the homeless young women in our study, second only to the drive to meet material needs. While associations with other street-involved peers is a known influence on survival sex participation (Cusick, 2002; Ferguson et al., 2011; Whitbeck et al., 2001), our study specifically investigated whether initiation into survival sex occurred due to the influence of a friend or family member. The increased suicide risk for homeless young women involved in survival sex found in our study, along with the high rates of victimization experienced by the young women while engaging in survival sex, and the regret and shame articulated by the young women involved, compel us to identify effective interventions to prevent and end young women’s participation in survival sex. The principal limitations of this study are convenience sampling strategies and limited power due to low sample size. Survey respondents were identified at service sites for homeless youth; given that there are differences between youth who access services and youth who do not (Bell & Walls, 2011; Ferguson et al., 2011), there is limited generalizability of the present findings. It seems reasonable to believe that those youth that do not access services might demonstrate a higher risk profile. Additional limitations may be due to recall bias and reluctance to report very personal and sensitive questions, despite the use of an ACASI survey. Given this situation, it is likely that there was an underreporting of much of the information. Future research should: 1) survey a larger population to ascertain if the similarity of the two groups is due to the low power of this study; 2) survey homeless young women who do not access services to assure a more representative sample of young women engaged in survival sex; and 3) continue efforts to identify factors that put specific young women at higher risk for involvement in survival sex as well as protective factors that might mitigate against participation. Findings from the study can help elucidate effective programmatic and policy responses to survival sex involvement among homeless young women. This study implies that efforts to prevent survival sex among young women and protect them from the grave consequences of involvement, may best be directed at providing the supports that can ameliorate those conditions that lead to homelessness. It also implies that, similar to the conclusions of other studies (Bell & Walls, 2011; Ferguson et al., 2011; Greene et al., 1999), youth who are homeless and without a supportive family to return to, need realistic alternatives to survival sex to meet basic material and economic needs. While there’s a critical need for programs directed at reducing risk behaviors among homeless young women, especially suicide prevention interventions, we need to ensure that our services are designed to support young people’s safety, stability and self-sufficiency. We need to strengthen our housing programs for homeless youth and invest in educational and employment training programs that can safeguard their futures and offer them a pathway out of homelessness. References Bell, S., & Walls, N. (2011). Correlates of engaging in survival sex among homeless youth and young adults. The Journal of Sex Research, 48(5), 423. Cusick, L. (2002). Youth prostitution: a literature review. 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Office of Juvenile Justice and Delinquency Prevention. Retrieved from https://www.ncjrs.gov/html/ojjdp/nismart/04/index.html Accessed 13.08.13. Kalichman, S. (1998). Preventing AIDS: A sourcebook for behavioral interventions. Mahwah, NJ: Lawrence Erlbaum Associates. National Alliance to End Homelessness. (2009). Homeless youth and sexual exploitation: Research findings and practice implications. http://www. endhomelessness.org/library/entry/homeless-youth-and-sexual-exploitation-research-findings-and-practice-impli Accessed 13.08.13. Robertson, M., & Toro, P. (1999). Homeless youth: research, intervention and policy. In Fosburg, & Dennis (Eds.), Practical lessons: The 1998 national symposium on homelessness research. Washington DC: US Department of Housing and Urban Development and U.S. Department of Health and Human Services. Seng, M. (1989). Child sexual abuse and adolescent prostitution: a comparative analysis. Journal of Adolescence, 24(95), 665–675. Stransky, M., & Finkelhor, D. 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