Sexual Risk Behaviors, Sexual Offenses, and Sexual Victimization Among Homeless Youth: A Systematic Review of Associations With Substance Use.

Sexual Risk Behaviors, Sexual Offenses, and Sexual Victimization Among Homeless Youth: A Systematic Review of Associations With Substance Use

TRAUMA, VIOLENCE, & ABUSE 1-22 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838015584371 tva.sagepub.com

Jessica A. Heerde1 and Sheryl A. Hemphill1,2

Abstract The use of substances among youth experiencing homelessness is an important issue in the context of addressing the developing burden of morbidities arising due to illness, injury, physical and mental health concerns, and low rates of health care utilization among this population group. Youth experiencing homelessness report engaging in and being victimized by various forms of sexual behavior. Of interest in this systematic review were published studies investigating substance use in its association with perpetration of sexual offenses, engagement in sexual risk behavior, or experience of sexual victimization among homeless youth. A systematic search of 12 psychology, health, and social science electronic databases was conducted. Search terms included ‘‘homeless*,’’ ‘‘youth,’’ ‘‘sex crimes,’’ ‘‘sexual victimization,’’ ‘‘survival sex,’’ ‘‘rape,’’ ‘‘drugs,’’ and ‘‘substance abuse.’’ Twenty-three studies were identified that met the inclusion criteria. No studies statistically examining substance use in its association with perpetrating sexual offenses were located. Findings showed substance use was generally associated with sexual risk behavior or sexual victimization; however, it remains unclear whether substance use precedes or follows these behaviors and experiences. It is possible substances are used by homeless youth as a means of coping with sexual risk behavior and victimization. Implications of the review findings in relation to prevention and intervention approaches aimed to decrease the incidence and severity of health concerns among homeless youth are discussed. Keywords homelessness youth, sexual risk behavior, sexual victimization, substance use, systematic review

The use of substances among youth experiencing homelessness is an important issue in the context of addressing the developing burden of morbidities arising due to illness, injury, physical and mental health concerns, and low rates of health care utilization among this population group. Homeless youth are recognized as having experienced incidences of family violence, childhood abuse (physical, psychological, and sexual), family conflict, and low levels of parent attachment (Bearsley-Smith, Bond, Littlefield, & Thomas, 2008; Martijn & Sharpe, 2006). For some of these youth, separation or removal from the family unit may have been the result of contact with child protective services (Heerde, Hemphill, Broderick & Florent, 2012). For these young people, the experience of homelessness creates additional vulnerability to negative physical, psychological and social, health and behavioral outcomes that do not occur in isolation from one another. Youth experiencing homelessness report engaging in and being victimized by various forms of violent behavior. It remains unclear whether the transition to homelessness precedes or follows substance use; however, homeless youth are reportedly at greater risk than homeless adults for developing

substance abuse problems after transitioning to homelessness (Johnson & Chamberlain, 2008). Attention should be given to understanding the factors that may contribute to or exacerbate substance use among these youth, including perpetration of sexual offenses, engagement in sexual risk behaviors, and experience of sexual victimization. Opportunities for increased understanding of these behaviors and experiences, and the influence of these on substance use, or vice versa, present opportunities for a prevention approach to decrease the incidence and severity of the many health and personal issues.

1

Learning Sciences Institute Australia, Faculty of Education and Arts, Australian Catholic University, Fitzroy, Victoria, Australia 2 School of Psychology, Faculty of Health Sciences, Australian Catholic University, Fitzroy, Victoria, Australia Corresponding Author: Jessica A. Heerde, Learning Sciences Institute Australia, Faculty of Education and Arts, Australian Catholic University, 115 Victoria Parade, Fitzroy, Victoria 3065, Australia. Email: [email protected]

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TRAUMA, VIOLENCE, & ABUSE

Of interest in this systematic review are published studies investigating substance use and sexual behavior among homeless youth. In this review, youth is defined according to the World Health Organisation (1986), as being between the ages of 10 and 24 years. Specifically, this review collates, appraises, and synthesizes studies investigating whether substance use is associated with (i) perpetration of sexual offenses, (ii) engagement in sexual risk behavior, or (iii) experience of sexual victimization.

Defining Homelessness, Sexual Offenses, Sexual Risk Behavior, Sexual Victimization, and Substance Use Homelessness. The ways in which homelessness is defined vary worldwide. However, such definitions are generally underpinned by a lack of access to safe and suitable physical shelter. Moreover, the experience of homelessness includes social marginalization, exposure to and potential perpetration of violence and other crimes (e.g., property crime), intensified risk for victimization and re-victimization, and possible engagement in health-compromising behaviors (e.g., substance use). The definition of homelessness utilized in this review is informed by those used in the United States and Canada in line with the published studies retained for analysis in this review: Homeless persons include individuals who have no suitable and permanent occupancy at a residence and who may be unsheltered (living directly on the streets or other spaces not intended for habitation) in emergency shelters or temporary accommodation or at risk of homelessness. Sexual offenses, sexual risk behavior, and sexual victimization. Consistent with the papers retained in this review, definitions for sexual behavior, offenses, and victimization used within this review are informed by descriptions of offenses, and victimization proposed by the U.S. Department of Justice (Office of Justice Programs, 2014a, 2014b; Office on Violence Against Women, 2013) and the Crown Prosecution Service in Canada (2013). Sexual offenses are defined as sexual behavior performed by an individual(s) against another person without consent, and includes rape (penetration of the vagina, mouth or anus by a penis, or another part of the body, or an object), sexual assault (forms of inappropriate touching of the genital area or a woman’s breasts), or other sexual behaviors (e.g., coerced sexual activity). Sexual risk behavior is defined as the exchange of sexual acts or practices by an individual in exchange for a commodity (or commodities), such as food, shelter, money, alcohol or drugs, or other goods from another person(s), and includes sex work (i.e., the consensual exchange of sexual services for payment or reward), survival sex (i.e., consensual or nonconsensual exchange of sexual practices for money, food, shelter, alcohol, or drugs), and street prostitution (the exchange of sex for money, gifts, drugs, a place to sleep, or other materials). Sexual victimization is defined as the threat of sexual harm or nonconsensual sexual handling experienced by an individual at the hands of another person(s) and includes experiencing those behaviors defined as sexual offenses.

Substance use. This review is underpinned by the definition of psychoactive substance misuse provided by the World Health Organization: The ingestion of a legal substance in amounts other than that which is consistent with health or medical guidelines or the ingestion of an illegal substance (World Health Organisation, 2013).

Associations Between Homelessness, Sexual Offenses, Risk Behavior, and Victimization Recent studies (Heerde & Hemphill, 2013; Heerde, Hemphill, & Scholes-Balog, 2014) have shown youth engage in and are victimized by various forms of property violence and physically violent behaviors while experiencing homelessness. Critically, in addition, young people experiencing homelessness frequently describe being raped and sexually assaulted, coerced into unwanted sexual activity, and engaging in street prostitution and survival sex (Heerde, Hemphill, & Scholes-Balog, 2014). Rates of these experiences and behaviors are generally higher for females compared to males. Studies examining the perpetration of sexual offenses by homeless youth are particularly lacking (Heerde, Hemphill, & Scholes-Balog, 2014). Understanding the vulnerabilities of homeless youth in relation to their potential for experiencing sexual victimization and/or engaging in sexual risk behavior or sexual offenses requires consideration of both the situational circumstances encountered while homeless and the coping capacity of these young people (Heerde & Hemphill, 2014; Heerde & Hemphill, 2015). The research literature provides some indication that associations between substance use and sexual offenses, sexual risk behavior, or sexual victimization may be anticipated. In an early study, Dembo, Williams, Schmeidler, Wothke, and Brown (1992) found family problems (including sexual abuse) were associated with alcohol and other drug use (e.g., marijuana). More recently, Raghavan, Bogart, Elliott, Vestal, and Schuster (2004) found alcohol and marijuana use and exposure to violence in the past year had statistically significant associations with sexual victimization. Similar findings were reported by Champion et al. (2004). Of particular concern are the traumaassociated effects of sexual risk behaviors and victimization for young people, including substance use. For instance, Danielson and Holmes (2004) found increased risk for adverse outcomes, including mental health concerns (e.g., depressive disorders, post-traumatic stress disorder [PTSD]), substance use and abuse, and delinquency were evident among youth with a history of sexual victimization. Risk of re-victimization was also high for these youth. In light of these findings, it is possible that substance use among homeless youth may be associated with sexual offenses, risk behavior, and victimization. It may be that use of substances among these youth is not merely related to experimentation within the realm of adolescent development or identity formation (Duff, 2010; Turner, Irwin, & Millstein, 1991). Rather, use of substances may be a coping mechanism utilized by homeless youth to facilitate survival (Heerde & Hemphill, 2014; Heerde & Hemphill, 2015). For instance, Lazarus and Folkman (1984)


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Table 1. Systematic Search Databases and Subject Headings. Discipline

Databases

Psychology Criminology Health Social work Multidisciplinary Area Homeless youth

ProQuest Psychology, PsycArticles, PsycInfo, Psychology and Behavioral Sciences Collection Australian Criminology Database (CINCH), Criminal Justice Collection, ProQuest Criminal Justice ProQuest Nursing and Allied Health Source Social Work Abstracts, SocIndex, ProQuest Social Sciences Academic Search Complete Subject headings ‘‘homeless*,’’ ‘‘youth,’’ ‘‘abandoned children,’’ ‘‘homeless children,’’ ‘‘homeless persons,’’ ‘‘homeless families,’’ ‘‘homeless men,’’ ‘‘homeless students,’’ ‘‘homeless women,’’ ‘‘homeless youth,’’ ‘‘homeless teenagers,’’ ‘‘street youth,’’ ‘‘at-risk youth,’’ ‘‘runaway teenagers,’’ ‘‘runaway children,’’ and ‘‘street children’’ ‘‘indecent assault,’’ ‘‘indecent exposure,’’ ‘‘rape,’’ ‘‘sex offenders,’’ ‘‘sexual aggression,’’ ‘‘sexual harassment,’’ ‘‘acquaintance rape,’’ ‘‘gang rape,’’ ‘‘assault and battery,’’ ‘‘pornography,’’ and ‘‘sex crimes’’ ‘‘sexual consent,’’ ‘‘criminal victimization,’’ ‘‘sexual victimization,’’ ‘‘victimization,’’ ‘‘crime victimization,’’ ‘‘victim*,’’ and ‘‘victims of crime’’ ‘‘transactional sex,’’ ‘‘prostitution,’’ ‘‘survival sex,’’ ‘‘trading sex,’’ ‘‘unsafe sex,’’ and ‘‘sex industry’’ ‘‘aerosol sniffing,’’ ‘‘inhalant abuse,’’ ‘‘solvent abuse,’’ ‘‘alcoholism,’’ ‘‘binge drinking,’’ ‘‘alcohol,’’ ‘‘drunkenness,’’ ‘‘drinking behavior,’’ ‘‘youth alcohol use,’’ ‘‘underage drinking,’’ ‘‘nicotine addiction,’’ ‘‘tobacco,’’ ‘‘cigarettes,’’ ‘‘marijuana,’’ ‘‘heroin,’’ ‘‘narcotics,’’ ‘‘cocaine,’’ ‘‘psychotropic drug use,’’ ‘‘drugs,’’ ‘‘pharmaceuticals,’’ ‘‘nonprescription drugs,’’ ‘‘psychotropic drugs,’’ ‘‘substance abuse,’’ and ‘‘drug abuse’’

Perpetration of sexual offenses Experience sexual victimization Sexual risk behavior Substance use

describe coping as efforts to manage demands which go beyond the means of an individual. In the case of homeless youth, substance use may be a mechanism drawn upon to decrease, change, or escape the strains faced while homeless and associated emotional discomfort, including that discomfort (e.g., shame and stigma) associated with perpetration of sexual offenses, engagement in sexual risk behaviors, or experience of sexual victimization. Homeless youth are a vulnerable and victimized population group, and although existing research indicates rates of substance use among these youth is greater than that of youth within the general population (Greene, Ennett, & Ringwalt, 1997), little is known about associations between substance use and perpetration of offenses, risk behavior, or victimization, including those of a sexual nature, for these young people.

Method Search Strategy This review was conducted in accordance with the guidelines and criteria for systematic reviews described by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher, Liberati, Tetzlaff, Altman, & Group, 2009). Systematic searches were conducted across 12 psychology, criminology, health, and social work electronic abstraction databases. The systematic search was conducted using database-specific controlled subject vocabulary (i.e., subject headings) and/or key words in the title and abstract to ensure the consistency of search terms across databases. In line with the objectives of this review search terms spanned five specific subject areas: (1) homeless youth, (2) perpetration of sexual offenses (e.g., rape), (3) sexual risk behavior (e.g., survival sex), (4) sexual victimization (e.g., sexual consent), and (5) substance use (e.g., alcohol). Table 1 provides a full list of databases and search terms used in conducting the systematic search.

Inclusion criteria. To obtain published studies of the highest relevance to the aims of the review, and in accordance with the PRISMA statement (Moher et al., 2009), inclusion criteria were established prior to conducting the systematic search. To be eligible for inclusion, published studies were required to (a) report on a sample of homeless youth (baseline age 12–24 years); (b) be published in English language; (c) contain a study abstract; (d) be published between 1990 and 2013; (e) present rates of substance use; and (f) report findings describing associations between substance use and (i) perpetration of sexual offenses, (ii) sexual risk behavior, or (iii) sexual victimization. As the authors sought to examine the most up-to-date research conducted relevant to the aims of the review, the date range for papers was restricted to those published in the past 23 years. Of utmost importance to the review was an investigation of internationally conducted studies, hence no restrictions were placed on the country of origin of the publication. Minimum sample sizes were not stipulated. Figure 1 provides the PRISMA diagram of published studies. The initial search identified in excess of 1,300 studies. The abstracts of retrieved studies were examined by the lead author to determine the initial relevance of the study for inclusion in the review. Where the article abstract did not sufficiently determine the relevance of each study for inclusion, the content of the study with reference to the aims of the review and inclusion criteria were inspected by the lead author. Each article was thoroughly read and assessed prior to final inclusion in the review, by the lead author. Additional papers for possible inclusion in the review were obtained through scanning the citations of included papers (resulting in an additional nine papers). To ensure the accuracy of data extraction and interpretation of relevant information, the second author checked the content of eight (30%) retrieved papers. This review utilizes the terms and concepts employed within each reviewed study to ensure the accurate presentation of specific forms of sexual offenses,



Identification

4

Records identified through database searching (n = 1,360)

Additional records identified through other sources (n = 9)

Included

Eligibility

Screening

Records after duplicates removed (n = 1,342)

Records screened (n = 1,342)

Full-text articles assessed for eligibility (n = 96)

Records excluded (n = 1,251)

Full-text articles excluded (n = 73)

Studies included in qualitative synthesis (n = 23)

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram of published studies. Qualitative synthesis in this context refers to the authors extracting information from eligible studies and describing and synthesizing the findings of these eligible studies.

sexual risk behavior, and sexual victimization reported among homeless youth. Further, although the causal direction of the relationship between sexual risk behaviors, sexual offenses, sexual victimization, and substance use cannot be determined through cross-sectional studies, the findings presented herein are described in line with the hypotheses and analyses conducted in each reviewed study. Five studies reporting contact with law enforcement (e.g., arrest, conviction for sexual behavior) were discarded (Chen, Thrane, Whitbeck, & Johnson, 2006; Coward Bucher, 2008; Ferguson et al., 2011; Kempf-Leonard & Johansson, 2007; McCarthy & Hagan, 1991); this was due to interest in examining self-reported perpetration of sexual offenses, sexual risk behavior, and sexual victimization. Contact with law enforcement was considered to be defined by authority figures (e.g., police) rather than youth themselves. Further, measures of ‘‘arrests’’ could not readily be classified into ‘‘perpetration,’’ ‘‘risk behavior,’’ or ‘‘victimization’’ so therefore did not fit within the aims of the review. Other retrieved studies discarded from the review were not consistent with the eligibility criteria underpinning the foci of the review such that they did not examine sexual offenses, risk behavior, or victimization as a

predictor or outcome of substance use; reported on a sample outside the specified age range (e.g., too old at baseline); reported on a sample not experiencing homelessness; did not analyze youth self-report data; examined experience of child sexual assault which occurred prior to entering homelessness; or were not available in English language. Abstracts detailing nonscholarly papers (e.g., gray literature), dissertations, or book reviews were also discarded from the review. Dissertations were excluded from the review on the basis that highquality dissertations were considered to have been converted into published papers that would have been identified through the systematic search. Calculation of effect sizes. To examine the degree of association between dependent and independent variables, effect sizes were calculated for the findings of reviewed studies (Tabachnick & Fidell, 2013). Effect sizes were calculated for all findings in the retained studies regardless of whether or not these were statistically significant. This is appropriate because effect size is not affected by sample size, and statistically nonsignificant results may display large effect sizes. A number of techniques for calculating effect sizes were employed due to the


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range of statistical analyses used in reviewed studies. To facilitate comparison of the magnitude of degree of relationship or strength of association, findings were converted to Cohen’s d, Cohen’s f2, or a Phi (j) coefficient (Tabachnick & Fidell, 2013). For effect sizes represented by Cohen’s d and Phi (j), coefficients between 0 and .30 were considered small, .31 and .49 medium, and greater than .50 large. Coefficients calculated using Cohen’s f2 were considered small in magnitude where the value was between 0 and .15, medium in magnitude where the value was between .16 and .34, and large where coefficients were greater than .35 (Tabachnick & Fidell, 2013).

Results Twenty-three studies met the inclusion criteria and were retained for analysis in this review. The characteristics of these studies, including country of origin, data collection site and method, sample size, gender distribution, and average age are presented in Table 2. With the exception of four studies conducted in Canada (Haley, Roy, Leclerc, Boudreau, & Boivin, 2004; Roy et al., 2011; Roy, Haley, Leclerc, Boudreau, & Boivin, 2007; Weber, Boivin, Blais, Haley, & Roy, 2004), all studies were conducted in the United States. All but three studies (Roy et al., 2007, 2011; Weber et al., 2004) were crosssectional in design. Study samples were generally recruited from both service (e.g., shelters) and street-based (e.g., street corners) sites. The size of analyzed samples ranged from 40 to 8,196.

Types and Rates of Substance Use by Homeless Youth Alcohol, marijuana, and stimulants were the most commonly used substances (refer Online Appendix 1, Table 1). Rates of alcohol use were reported in eight studies; reported rates varied substantially across the studies. Rates of lifetime alcohol use for entire samples of homeless youth ranged from 75% in the United States (Walls & Bell, 2011) to 99% in Canada (Roy et al., 2007). Rates for lifetime binge drinking were reported as being 46% in one Canadian sample (Weber et al., 2004). Several studies described rates for past month alcohol use. Gleghorn, Marx, Vittinghoff, and Katz (1998) and Walls and Bell (2011) found 50% of their samples reporting using alcohol in the past month. Weber, Boivin, Blais, Haley, and Roy (2004) described 28% of youth in their Canadian sample reportedly used alcohol twice a week in the past month, while 10% described daily use over this period. Incidences of marijuana use were reported in six studies using data from U.S. samples. Of these studies, two reported lifetime rates of 74% (Bailey, Camlin, & Ennett, 1998) and 92% (Gleghorn, Marx, Vittinghoff, & Katz, 1998). Tyler, Gervais, and Davidson (2013) found 45% of youth in their sample described marijuana use in the past 6 months. Martinez et al. (2011) reported rates of marijuana use across various timeframes. Among the sample, 56% reported using marijuana daily, 22% weekly, and 20% reported occasional (or never) using marijuana.

Rates of use of various forms of stimulants were presented in five studies, all from the United States (Bailey et al., 1998; Chen, Tyler, Whitbeck, & Hoyt, 2004; Gleghorn et al., 1998; Stein, Milburn, Zane, & Rotheram-Borus, 2009; Walls & Bell, 2011). Use of amphetamines and cocaine were the most commonly described stimulants reportedly used among youth across the reviewed studies. Rates of amphetamines use ranged from 13% (Chen et al., 2004) to 76% (Gleghorn et al., 1998). Incidences of cocaine (injectable) or crack (smokable form of cocaine) were assessed in terms of lifetime, past year, and past month use. Bailey, Camlin, and Ennett (1998) reported 16% of youth described lifetime cocaine use. Substantially higher rates were reported in another study (Gleghorn et al., 1998). A fifth of youth described lifetime crack use in one study, while 5% described using crack in the last month (Walls & Bell, 2011). Rates of other substances reported across reviewed studies were lower than that of alcohol, marijuana, or amphetamines and included organic opiate analgesics (e.g., codeine), semisynthetic opiates (e.g., heroin), sedatives (e.g., ketamine), hallucinogens and hypnotics (e.g., ecstasy), other stimulants (e.g., nicotine and cocaine), and inhalants. Rates for concurrent use of multiple substances, and drug use (including injection), addiction, and dependence were also reported in some reviewed studies (refer Online Appendix 1).

Cross-Sectional Associations Between Sexual Offenses, Sexual Risk Behavior, Sexual Victimization, and Substance Use Statistical analyses investigating whether the perpetration of sexual offenses was associated with substance use were not presented in any reviewed study. In 20 reviewed studies, the study design was cross-sectional and described analyses whereby both sexual risk behavior and sexual victimization were examined in their association with use of substances. No reviewed studies presented analyses investigating engagement in sexual risk behavior or sexual victimization and use of sedatives and hypnotics or solvents and inhalants, or sexual victimization and use of stimulants and hallucinogens or organic and synthetic opiate analgesics. Use of nicotine and tobacco were not reported in any reviewed study. Sexual risk behavior. The findings from 17 cross-sectional studies presenting analyses examining associations between sexual risk behavior (e.g., survival sex) and substance use, including effect sizes, are presented in Table 3. Alcohol. Few studies statistically analyzed whether alcohol use was associated with engagement in sexual risk behavior; however, findings from these studies conducted in the United States showed positive associations between alcohol use and sexual risk behavior (survival sex). In one study, participation in (exchanging) and receiving survival sex were positively correlated with alcohol use (Bailey et al., 1998). A larger degree of association between participation in (exchange of) survival sex


6


United States

Longitudinal Longitudinal

Cross-sectional Cross-sectional

United States

United States Canada Canada United States United States United States United States United States United States United States

Martinez et al. (2011)d

Rice, Stein, and Milburn (2008)

Roy, Haley, Leclerc, Boudreau, and Boivin (2007) Roy et al. (2011)

Simons and Whitbeck (1991)

Stein, Milburn, Zane, and Rotheram-Borus (2009) Tyler, Gervais, and Davidson (2013)

Tyler, Hoyt, and Whitbeck (2000a)

Tyler, Hoyt, Whitbeck, and Cauce (2001)b

Tyler, Whitbeck, Hoyt, and Cauce (2004)b

Tyler, Whitbeck, Hoyt, and Yoder (2000b)

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

United States

Cross-sectional

Cross-sectional

Cross-sectional

Huba et al. (2000)

Canada

Cross-sectional

United States

Gleghorn, Marx, Vittinghoff, and Katz (1998) Greene, Ennett, and Ringwalt (1999)b

Haley, Roy, Leclerc, Boudreau, and Boivin (2004)c

Cross-sectional

United States

Chen, Tyler, Whitbeck and Hoyt (2004)

Cross-sectional

United States

Bailey, Camlin, and Ennett (1998)

Study Design

Country of Origin

Authors

Table 2. Description of Studies Meeting Review Criteria.

Service and streetbased sites Service and streetbased sites Service and streetbased sites Service and streetbased sites Service and streetbased sites Service and streetbased sites

Service-based sites

Service-based sites

Service and streetbased sites Service-based sites

Street-bases sites

Service-based sites

Service-based sites

Service and streetbased sites

Service and streetbased sites Service and streetbased sites Street-based sites

Site of Data Collection

Structured interview



602

372

372

361

249

Structured interview Structured interview

501

40

352

118

Total 8,196 Males 4,111 Females 4,085 Total 186 IDU 83 Non-IDU 103 696

542

Street 528 Shelter 631

1121

361

327

Baseline Sample Size







Survey


Survey




Data Collection Method

60.0

45.4

45.4

100.0

55.0

49.5

100.0

28.0

47.5

50.0

42.0

49.0

0.0

Street 38.8 Shelter 60.8

36.0

100.0

Majoritya

Gender (% Female)

(continued)

Range: 12–22 Mean: 16.0 Range: 12–21 Median: 17.0 Range: 13–21 Mean: 13.3 Range: 12–22 Mean: 16.0 Mean: 17.0 (males) Mean: 16.0 (females)

Range: 12–20 Mean: 17.0 Range: 14–25 Mean: 16.6 Range: 14–23 Mean: 20.0 Range: 14–18 68%: 16–17 Range: 12–21 Mean: 17.0 Range: 14–21

Range: 12–23 Mean: 19.0

Range: 12–21 Mean: 17.9 (street) Mean: 16.1 (shelter) Range: 14–23 Mean: 21.1 (involved) Mean: 20.5 (never involved) Mean: 19.1 (males) Mean: 18.4 (females)

Range: 14–21 Mean: 17.0 Range: 12–22 Mean: 16 62% over 18

Age (Years)

7


Cross-sectional

United States

Cross-sectional

Cross-sectional

United States

United States

Longitudinal

Cross-sectional

United States Canada

Cross-sectional

Study Design

United States

Country of Origin

Service and streetbased sites

Service and streetbased sites Service and streetbased sites

Service and streetbased sites Service and streetbased sites Service-based sites

Site of Data Collection






Structured survey

Data Collection Method

974

502

428

148

1,625

432

Baseline Sample Size

Midwest 60 Seattle 45.4

72.0

56.3

100.0

47.1

34.7

Gender (% Female)

Range: 12–23 78%: 16–21 Range: 10–25 Mean: 18.3 Range: 10–25 Mean: 18.8 Range: 16–19 Mean: 17.4 Range: 12–22 Mean: 16.6 (males) Mean: 16.0 (females) Range: 12–22 Mean: 16.3 (Midwest) Mean: 17.1 (Seattle)

Age (Years)

Note. Service sites include shelters and drop-in centers. Street-based sites include street corners, populated areas/blocks, parks, alleys, bars, and fast-food restaurants. Government providers refer to examination of child protection records. IDU ¼ Injection drug user. a Exact percentage of female participants not reported. bSame analyzed sample. cInvolved ¼ youth involved in survival sex; never-involved ¼ no history of involvement in survival sex. dData collected as part of the AIDS Evaluation of Street Outreach Project.

Whitbeck, Hoyt, Yoder, Cauce, and Paradise (2001)

Weber, Boivin, Blais, Haley, and Roy (2004) Whitbeck, Chen, Hoyt, Tyler, and Johnson (2004) Whitbeck, Hoyt, and Wa-Ning (2000)

Unger, Kipke, Simon, Montgomery, and Johnson (1997) Walls and Bell (2011)

Authors

Table 2. (continued)

8


Substance Use

Greene et al. (1999)

Gleghorn et al. (1998)

Chen et al. (2004) Chi-square (heroin vs. stimulant use) Logistic regression

Multivariate logistic regression

Survival sex

History of trading sex for money, food, drugs, or shelter

Survival sex

Heroin Stimulants

Alcohol Marijuana Cocaine Other drugs Injection drug use

Pearson correlations Path analysis

Tetrachoric and Polychoric Correlations

Statistical Analysis Method

Drug use

Substance use and sexual risk behavior. Survival sex Alcohol Bailey Marijuana et al. Crack (1998) Hallucinogens Heroin Substance dependency

Author

Risky Sexual Behavior/Sexual Victimization Alcohol use (analytic sample): Positive association with participating in survival sex (r ¼ .52*) Positive association with receiving survival sex (r ¼ .35*) Marijuana use (analytic sample): Positive association with participating in survival sex (r ¼ .68*) Positive association with receiving survival sex (r ¼ .55*) Crack use (analytic sample): Positive association with participating in survival sex (r ¼ .72*) Positive association with receiving survival sex (r ¼ .26*) Hallucinogen use (analytic sample): Positive association with participating in survival sex (r ¼ .37*) Positive association with receiving survival sex (r ¼ .50*) Heroin use (analytic sample): Positive association with participating in survival sex (r ¼ .54*) Positive association with receiving survival sex (r ¼ .48*) Substance dependency (analytic sample): Positive association with participating in survival sex (r ¼ .54*) No association with receiving survival sex (r not stated, ns) Drug use (analytic sample): Positive association with survival sex (r ¼ .34*) Increased survival sex (b ¼ .24**) Heroin/stimulant use (analytic sample): More likely to report a history of trading sex (w2 not stated, ns) Increased history of trading sex (OR ¼ 2.4, p not stated) Primary stimulant use (analytic sample): Increased primary stimulant use (OR ¼ 1.9, p not stated) Primary heroin use (analytic sample): No effect on trading sex (OR not stated, ns) Alcohol use (shelter sample): Increased survival sex (AOR ¼ 2.50***) Marijuana use (shelter sample): Increased survival sex (AOR ¼ 2.50***) Cocaine use (shelter sample): Increased survival sex (AOR ¼ 5.60***) Other drug use (shelter sample): Increased survival sex (AOR ¼ 3.60***) Injection drug use (shelter sample): Increased survival sex (AOR ¼ 8.80***) Alcohol use (street sample): No effect on survival sex (AOR ¼ 1.90, ns) Marijuana use (street sample): Increased survival sex (AOR ¼ 2.80***)

Findings

Table 3. Cross-Sectional Studies Reporting Associations Between Sexual Risk Behavior or Sexual Victimization and Substance Use.

(continued)

d ¼ 0.25

d ¼ 0.15

d ¼ 0.52

d ¼ 0.31

d ¼ 0.41

d ¼ 0.22

d ¼ 0.22

d ¼ 0.15

n/a

n/a d ¼ 0.21

d ¼ 0.72 f2 ¼ .49

d ¼ 1.29 n/a

d ¼ 1.29 d ¼ 1.39

d ¼ 0.80 d ¼ 1.15

d ¼ 2.09 d ¼ 0.54

d ¼ 1.86 d ¼ 1.31

d ¼ 1.22 d ¼ .74

Effect Size

9


Risky sexual behavior

Survival sex

Substance use

Substance use

Prostitution

Trading sex

HIV Sex risk behavior

HIV Drug risk behavior Substance problema

Alcohol/drug use

Survival sex

Recent drug use

Martinez et al. (2011) Rice et al. (2008) Simons and Whitbeck (1991) Stein et al. (2009)

Tyler et al. (2000a) Tyler et al. (2000b)

Survival sex Risky sex with men Risky sex with women

Substance abuse historya

Huba et al. (2000)

Survival sex

Steroid injection Drug injection

Substance Use

Risky Sexual Behavior/Sexual Victimization

Haley et al. (2004)

Author



Path analysis

Structural equation modeling

Pearson correlations Logistic regression

Chi-square analysis (current injection drug use vs. part or noninjection drug use) Path analysis

Logistic regression



Substance use (analytic sample): Positive association with survival sex (r ¼ .17**) Substance use (male sample): No association with survival sex (r ¼ .06, ns) Substance use (female sample): Positive association with survival sex (r ¼ .31***) Alcohol/drug use (analytic sample): Positive association with trading sex (r ¼ .28**) Substance use (analytic sample): Positive association with risky sexual behavior (r ¼ .47**) Increased risky sexual behavior (b ¼ .41**)

HIV Drug risk behavior (analytic sample): Positive association with HIV sex risk behavior (r ¼ .15**) Substance problem (runaway sample): No association with prostitution (r ¼ .10, ns) No effect on prostitution (OR ¼ .00, ns)

Cocaine use (street sample): Increased survival sex (AOR ¼ 2.40***) Other drug use (street sample): Increased survival sex (AOR ¼ 1.80***) Injection drug use (street sample): Increased survival sex (AOR ¼ 3.00***) Steroid injection (analytic sample): Increased survival sex (AOR ¼ 3.90, p not stated) Drug injection (analytic sample): Increased survival sex (OR ¼ 2.40, p not stated) Substance abuse history (male sample): Increased survival sex (OR ¼ 2.88***) Substance abuse history (male sample): Increased risky sex with men (OR ¼ 1.40***) Substance abuse history (male sample): Increased risky sex with women (OR ¼ 2.79***) Substance abuse history (female sample): Increased survival sex (OR ¼ 6.19***) Substance abuse history (female sample): Increased risky sex with men (OR ¼ 2.34***) Substance abuse history (female sample): Increased risky sex with women (OR ¼ 2.70***) Recent drug use (current injection drug use): Higher rates of recent survival sex (w2 not stated, p < .05)

Findings

(continued)

d ¼ 1.06 d ¼ 0.40

d ¼ 0.58

d ¼ 0.65

d ¼ 1.36

d ¼ 0.35

d ¼ 0.99 d ¼ 0.0

d ¼ 0.33

n/a

d ¼ 0.55

d ¼ 0.47

d ¼ 0.44

d ¼ 0.57

d ¼ 0.19

d ¼ 0.58

d ¼ 0.21

d ¼ 0.33

d ¼ 0.26

d ¼ 0.14

d ¼ 0.21

Effect Size

10


Walls and Bell (2011)

Tyler et al. (2001) Tyler et al. (2013)

Author



Trading sex

Survival sex

Alcohol use Marijuana use

Alcohol Ecstasy Methamphetamine Inhalant Crack Valium Heroin Ketamine Morphine

Pearson correlations


Survival sex


Hard drug use

Substance Use


Hard drug use (analytic sample): No association with survival sex (r ¼ .00, ns) Alcohol use (analytic sample): Positive association with trading sex (r ¼ .25**) Increased trading sex (b ¼ .31***) Marijuana use (analytic sample): Positive association with trading sex (r ¼ .33**) Increased trading sex (b ¼ .45***) Substance use (lifetime drug use model, analytic sample): Alcohol (analytic sample) Increased survival sex (OR ¼ 2.48**) Ecstasy (analytic sample) No effect on survival sex (OR ¼ 1.54, ns) Methamphetamine (analytic sample) No effect survival sex (OR ¼ 1.53, ns) Inhalants (analytic sample) Increased survival sex (OR ¼ 2.10*) Crack (analytic sample) Increased survival sex (OR ¼ 2.41***) Valium (analytic sample) Decreased survival sex (OR ¼ .36*) Dextromethorphan (analytic sample) Decreased survival sex (OR ¼ .48*) Heroin (analytic sample) No effect on survival sex (OR ¼ 1.26, ns) Ketamine (analytic sample) No effect on survival sex (OR ¼ 1.06, ns) Morphine (analytic sample) Increased survival sex (OR ¼ 1.79*) Substance use (recent drug use model, analytic sample): Alcohol (analytic sample) Decreased survival sex (OR ¼ .57*) Ecstasy (analytic sample) Decreased survival sex (OR ¼ .46*) Methamphetamine (analytic sample) Decreased survival sex (OR ¼ .53**) Inhalants (analytic sample) No effect on survival sex (OR ¼ .73, ns) Crack (analytic sample) No effect on survival sex (OR ¼ .88, ns) Valium (analytic sample) No effect on survival sex (OR 1.24, ns) Dextromethorphan (analytic sample)

Findings

(continued)

d ¼ 0.12

d ¼ 0.07

d ¼ 0.17

d ¼ 0.35

d ¼ 0.43

d ¼ 0.31

d ¼ 0.32

d ¼ 0.03

d ¼ 0.13

d ¼ 0.41

d ¼ 0.56

d ¼ 0.49

d ¼ 0.41

d ¼ 0.23

d ¼ 0.24

d ¼ 0.50

d ¼ 0.70 f2 ¼ .59

d ¼ 0.52 f2 ¼ .37

d ¼ 1.0

Effect Size

11


Sexual deviant subsistence strategies

Alcohol/drug use

Whitbeck et al. (2001) Substance use Tyler et al. (2000a) Tyler et al. (2001)

Tyler et al. (2004)

Dangerous sexual encounters

Alcohol/drug use

Whitbeck et al. (2000)

Hard drugs

Hard drug use

Sexual victimization


and sexual victimization. Alcohol/drug use Sexual victimization

Survival sex

Alcohol abuse Drug abusea

Substance Use



Author


Multinomial logistic regression


Pearson correlations


Pearson corrlations

Ordinary least squares regression Logistic regression


Alcohol/drug use (analytic sample): Positive association with sexual victimization (r ¼ .25**) Hard drug use (analytic sample): No association with sexual victimization (r ¼ .10, ns) No effect on sexual victimization (OR ¼ 1.10, ns) Hard drugs (female sample): Increased sexual victimization by a stranger (OR ¼ 1.28*) No effect on sexual victimization by a friend/acquaintance (OR ¼ 1.11, ns) Hard drugs (male sample): No effect on sexual victimization by a stranger (OR ¼ .90, ns)

d ¼ 0.01

No effect on survival sex (OR ¼ .98, ns) Heroin (analytic sample) Decreased survival sex (OR ¼ .44*) Ketamine (analytic sample) No effect on survival sex (OR ¼ 6.22, ns) Morphone (analytic sample) No effect on survival sex (OR ¼ .58, ns) Substance use (full model, analytic sample): Methamphetamine (lifetime use, analytic sample): Increased survival sex behavior (OR ¼ 2.23**) Inhalants (lifetime use, analytic sample): Increased survival sex behavior (OR ¼ 2.79**) Valium (lifetime use, analytic sample): Increased survival sex behavior (OR ¼ 2.23**) Heroin (lifetime use, analytic sample): Decreased survival sex behavior (OR ¼ .37***) Alcohol abuse (analytic sample): No effect on survival sex (OR ¼ 1.74, ns) Drug abuse (analytic sample): No effect on survival sex (OR ¼ 1.71, ns) Alcohol/drug use (male sample): Positive association with dangerous sexual encounters (r ¼ .40**) Alcohol/drug use (female sample): Positive association with dangerous sexual encounters (r ¼ .35**) Alcohol/drug use (analytic sample): Increased sexual deviant subsistence strategies (OR ¼ 1.05*)

(continued)

d ¼ 0.03

d ¼ 0.06 d ¼ 0.03

d ¼ 0.20 d ¼ 0.02

d ¼ 0.52

d ¼ 0.01

d ¼ 0.75

d ¼ 0.87

d ¼ 0.13

d ¼ 0.13

d ¼ 0.24

d ¼ 0.19

d ¼ 0.25

d ¼ 0.19

d ¼ 0.30

d ¼ 1.01

d ¼ 0.45

Effect Size

Findings

12


Sexual abuse or assault



Alcohol disorder Drug disorder

Alcohol abuse Drug abusea

Alcohol/drug use

Unger et al. (1997)




Ordinary least squares regression Logistic regression

Logistic regression



No effect on sexual victimization by a friend/acquaintance (OR ¼ 1.05, ns) Alcohol use (analytic sample): Positive association with sexual victimization (r ¼ .31**) No effect on sexual victimization (b ¼ .08, ns) Marijuana use (analytic sample): Positive association with sexual victimization (r ¼ .26**) Increased sexual victimization (b ¼ .17*) Alcohol disorder No effect on sexual abuse or assault (OR ¼ 1.41, ns) Drug disorder (analytic sample): No effect on sexual abuse or assault (OR ¼ 1.25, ns) Alcohol abuse (analytic sample): No effect on sexual victimization (OR ¼ 1.11, ns) Drug abuse (analytic sample): Increased sexual victimization (OR ¼ 1.75*) Alcohol/drug use (analytic sample): Positive association with sexual victimization (r ¼ .15**) No effect on sexual victimization (OR ¼ 1.02, ns)

Findings

d ¼ 0.30 d ¼ 0.00

d ¼ 0.13

d ¼ 0.13

d ¼ 0.06

d ¼ 0.08

d ¼ 0.54 f2 ¼ .16

d ¼ 0.65 f2 ¼ .16

d ¼ 0.01

Effect Size

Note. ns ¼ not statistically significant; OR ¼ odds ratio; AOR ¼ adjusted odds ratio; w2 ¼ chi-square; b ¼ unstandardized beta coefficient; b ¼ standardized beta coefficient; r ¼ correlation coefficient; d ¼ Cohen’s d; f2 ¼ Cohen’s f2. *p < .05. **p < .01. ***p < .001.


Alcohol use Marijuana use

Substance Use


Tyler et al. (2013)

Author


Heerde and Hemphill

13

and alcohol use (d ¼ 1.22) was found than for receiving survival sex (d ¼ 0.74). Similarly, Tyler et al. (2013) found a positive correlation between trading sex and alcohol use, with trading sex associated with increased alcohol use in adjusted multivariate analyses, with a moderate effect size (f2 ¼ .37). Greene, Ennett, and Ringwalt (1999) also showed alcohol use was associated with a twofold increase in the odds of engagement in survival sex for youth residing in shelters, but not for those youth living directly on the streets, with small effect sizes. Similar findings were reported by Walls and Bell (2011) with respect to lifetime alcohol use; however, found recent alcohol use was related to decreased survival sex. Cannabinoids. Several U.S.-based studies showed associations between cannabinoids (marijuana) and sexual risk behavior. Positive associations between marijuana use and engagement in survival sex were consistently reported in three reviewed studies. Specifically, participating in, and receiving, survival sex were correlated with increased marijuana use, with large effect sizes (d ¼ 1.86 and d ¼ 1.31, respectively; Bailey et al., 1998). Another study showed trading sex was positively correlated with marijuana use, and effect which held in adjusted multivariate analyses, with a large effect size (f2 ¼ .59; Tyler, Gervais, & Davidson, 2013). Likewise, after adjustment for covariates, marijuana use was associated at least a two-and-a-half fold increase in the odds of engagement in survival sex among youth residing directly on the streets and those living in a shelter (Greene, Ennett, & Ringwalt, 1999). Stimulants and hallucinogens. Four studies investigated associations between stimulant or hallucinogen use and sexual risk behavior with variation in findings apparent. One study reported findings of correlation analyses showing participation in and receipt of survival sex were positively correlated with use of both crack and hallucinogens (Bailey et al., 1998). Effect sizes for crack use were greater than that of hallucinogen use for participation in survival sex, and hallucinogen use greater than that of crack use for receipt of survival sex. In the three studies adjusting for covariates, use of crack and stimulants were generally associated with sexual risk behavior, while findings for cocaine and methamphetamines were mixed. Specifically, Gleghorn et al. (1998) found the odds for stimulant use were increased by nearly 2 times among youth reporting a history of trading sex for money, food, drugs, or shelter (effect size d ¼ 0.15). Elsewhere, the odds of engagement in survival sex were doubled for youth who reported crack use, but not amphetamine use after adjusting for covariates (including gender, age, ethnicity, family history of substance use, and other drug use; Walls & Bell, 2011). One study reported findings for cocaine use; it was associated with a 2-fold increase in odds of engagement in survival sex for street youth, and shelter use by more than 5 times (Greene et al., 1999). Organic and synthetic opiate analgesics. Three studies examined use of heroin with variation in findings apparent. One study found a positive correlation between survival sex and heroin

use, such that participation in, and receipt of survival sex, were associated with increased heroin use, with large effect sizes (d ¼ 1.29 and d ¼ 1.39, respectively; Bailey et al., 1998). Conversely, Gleghorn et al. (1998) found no statistically significant association between history of trading sex for money, food, drugs, or shelter on the odds of heroin use after adjustment for covariates. Likewise, Walls and Bell (2011) found lifetime heroin use was not associated with engagement in survival sex among their sample; however, recent (past month) use reduced engagement in survival sex by half (effect size d ¼ 0.45). Nonspecific drug use. Associations between sexual risk behavior and substance use, including intravenous drug use and use of substances indicated by aggregate measures examining the use of multiple substances, were reported in the majority of reviewed studies, with inconsistent findings. Intravenous drug use. Findings of reviewed studies were consistent in showing positive associations between engagement in sexual risk behavior and intravenous drug use. Martinez et al. (2011) found higher rates of survival sex among youth in their sample reporting current, compared to past, injection drug use. Rice, Stein, and Milburn (2008) found engagement in HIV sexual risk behaviors, defined as participation in trading sex for money, pornography (photos, video, or film), or a place to stay, and the number of sex partners with whom individuals had engaged in unprotected vaginal and/or anal sex, was positively correlated with HIV drug risk behavior (including injection of stimulants or amphetamines, crack or cocaine, heroin, or other drugs). In another study, Haley, Roy, Leclerc, Boudreau, and Boivin (2004) found injection of both steroids and other drugs were associated with a 3- and 2-fold increase, respectively, in the odds of engagement in survival sex after adjustment for covariates (effect sizes d ¼ 0.33 and d ¼ 0.21 respectively). Similarly, Greene et al. (1999) found intravenous drug use was associated with increased odds for participation in survival sex among youth residing on the street and in shelters. Effect size analyses showed a greater magnitude association for shelter compared to street-based youth. Unspecified substance use. Associations between substance use, indicated by aggregate measures of use of various substances, and sexual risk behavior were investigated in seven reviewed studies, with findings generally consistent in showing positive associations. In one study, engagement in survival sex was positively correlated with drug use, an association that remained after adjusting for covariates (including age at which youth became homeless, time homeless, deviant peer relationships, and engagement in deviant subsistence strategies [e.g., stealing money, break and enter]; f2 ¼ .49; Chen et al., 2004). Elsewhere, participation in survival sex and substance use were not correlated for either males or females (Stein et al., 2009). Whitbeck, Hoyt, and Wa-Ning (2000) and Whitbeck, Hoyt, Yoder, Cauce, and Paradise (2001) conducted several studies investigating associations between substance use and sexual risk behavior. In one study, drug and alcohol use among both male


14


and female youth in their sample was positively correlated with dangerous sexual encounters (trading sex for food, shelter, money, or drugs) (Whitbeck, Hoyt, & Wa-Ning, 2000). In a later study, drug (including marijuana, cocaine, LSD, methamphetamines) and alcohol use were associated with increased odds for engagement in sexual deviant subsistence strategies (defined as engaging in prostitution for money, trading sex for food, shelter, money, or drugs) after adjusting for covariates (including age, gender, family abuse, age at entering homelessness, and lifetime experience of homelessness) (Whitbeck, Hoyt, Yoder, Cauce, & Paradise, 2001). Tyler, Hoyt, and Whitbeck (2000a), Tyler, Hoyt, Whitbeck, and Cauce (2001), and Tyler, Whitbeck, Hoyt, and Yoder (2000b) generally reported converse findings across several studies. Tyler et al. (2001) found hard drug use and engagement in survival sex were not correlated. In another study, although a positive cross-sectional correlation was found between engagement in trading sex for food, shelter, money, or drugs and combined alcohol and drug use (Tyler, Hoyt, & Whitbeck, 2000a), this association did not reach statistical significance after adjustment for covariates (including childhood sexual abuse, age at which youth became homeless, time homeless, and peer engagement in trading sex). Similarly, Tyler and associates (2000b) found although substance use (including beer, marijuana, cocaine, amphetamine, and hard drug use) and risky sexual behavior (defined as trading sex for food or shelter or for money or drugs) were positively correlated, after controlling for covariates including early sexual abuse, time homeless, and peers engaging in risky sexual behavior, this association did not reach statistical significance. Substance abuse and dependency. Four studies showed no clear associations between sexual risk behavior and abuse of, or dependence on, substances. One study found a positive correlation, with a large effect size, between participation in survival sex and symptoms of substance dependency; however, the correlation between receipt of survival sex and symptoms of substance dependency did not reach statistical significance (Bailey et al., 1998). Likewise, Simons and Whitbeck (1991) found no statistically significant correlation between engagement in prostitution and substance use problems. Similarly, Whitbeck, Chen, Hoyt, Tyler, and Johnson (2004) found neither alcohol nor drug abuse (measured according to the UM-CIDI) had a statistically significant association with survival sex in adjusted analyses. In contrasting results (Huba et al., 2000), survival sex was associated with over a 6-fold increase in the odds of substance abuse for females. The effect size for this association was moderate (d ¼ 0.44). The odds for substance abuse among males was half that of females (d ¼ 25). In the same study, substance abuse was increased by almost 1½ times where males reported engaging in risky sex (e.g., unprotected sex) with men and over 2 times for risky sex with women. For females, risky sex with both men and women was associated with a 2-fold increase in the odds of substance abuse, with moderate-large effect sizes (d ¼ 0.47 and d ¼ 0.55, respectively).

Sexual victimization. Analyses investigating possible associations between use of substances and sexual victimization were presented in four studies. Across all studies, sexual victimization was explored using an aggregate measure of various forms of sexual victimization (e.g., forced sexual contact, assault, and rape). No studies examined use of stimulants and hallucinogens, organic and synthetic opiate analgesics, sedatives and hypnotics, solvents and inhalants, or intravenous drugs. Table 3 presents the findings, including effect sizes, from these four studies. Alcohol and cannabinoid use. Only one study examined if sexual victimization was associated with either alcohol or marijuana use; findings showed that sexual victimization, including having been forced to do something sexual or experience of sexual assault or rape since leaving home, was positively correlated with alcohol use with a moderate effect size (d ¼ 0.65). This association did not maintain statistical significance after controlling for covariates (including age at which youth first left home, time homeless, and experience of physical and sexual abuse; Tyler et al., 2013). In the same study, sexual victimization was associated with marijuana use, after adjusting for covariates with a moderate effect size (f2 ¼ .16). Nonspecific drug use. Some associations between sexual victimization and drug use were evident. In their study, Tyler et al. (2001) found sexual victimization, indicated by forced sexual touching and sexual assault, was not correlated with hard drug use (defined as use of cocaine/crack, acid, mushrooms, ecstasy, and heroin/opium), and did not reach statistical significance in multivariate analyses. Drug and alcohol use was also positively correlated with sexual victimization (indicated by having been forced to do sexual things and sexual assault or raped) in another cross-sectional study (d ¼ 0.30), however did not maintain statistical significance after controlling for covariates (as previously described; Whitbeck et al., 2001). The effect of drug use was examined in two further studies by Tyler et al. (2000a) and Tyler, Whitbeck, Hoyt, and Cauce (2004) with opposing findings. Although findings showed a positive correlation between alcohol and drug use in one study (Tyler et al., 2000a), later findings showed hard drug use (such as use of cocaine/crack, acid, mushrooms, ecstasy, and heroin/opium) was associated with increased odds for sexual victimization (as previously described) by a stranger for females (d ¼ 0.06) but not males. Hard drug use displayed no statistically significant effect on sexual victimization by a friend/acquaintance for either males or females in this study (Tyler, Whitbeck, Hoyt, & Cauce, 2004). Substance abuse and dependency. Two studies examined if substance abuse and sexual victimization were associated; findings showed that neither alcohol nor drug abuse were associated with sexual victimization. Specifically, findings showed sexual abuse or assault had no effect on the odds of reporting either an alcohol or drug disorder (effect sizes d ¼ 0.08 and d ¼ 0.06, respectively; Unger, Kipke, Simon, Montgomery, & Johnson,


Heerde and Hemphill

15

1997). In a later study, Whitbeck et al. (2004) found drug abuse, but not alcohol abuse, was associated with almost a 2-fold increase in sexual victimization (including having been asked to do something sexual and having been sexually assaulted or raped).

Longitudinal Associations Between Substance Use, Sexual Offenses, Sexual Risk Behavior, and Sexual Victimization The results of two studies describing study hypothesis and consequent empirical investigation examining longitudinal associations between engagement in sexual risk behavior or experience of sexual victimization and substance use, and one study describing a study hypothesis and consequent empirical investigation examining the longitudinal association between substance use and engagement in sexual risk behavior, including effect sizes, are presented in Table 4. No reviewed study presented statistical analyses investigating longitudinal associations between substance use and the perpetration of sexual offenses. Sexual risk behavior. Few studies statistically analyzed whether sexual risk behavior was longitudinally associated with substance use (or vice versa); however, findings from two Canadian studies showed predictive associations. Roy et al. (2011) and Roy, Haley, Leclerc, Boudreau, and Boivin (2007) investigated relations between participation in survival sex and risk for initiation into drug injection, in unadjusted and adjusted analyses. In both studies, engagement in survival sex was associated with at least a 2-fold increase in the risk for initiation into drug injection in unadjusted analyses, with small effect sizes. After adjustment for covariates, including age, peer relationships, lifetime sexual abuse, lifetime experience of having been raped, and other substance use (such as alcohol and heroin), these associations did not reach statistical significance (effect sizes d ¼ 0.25 and d ¼ 0.26). In another study, Weber et al. (2004) described both positive and negative relationships between use of various substances and risk for initiation into prostitution in adjusted analyses, among their Canadian sample. Covariates included intra- and extra-familial sexual abuse, age at first episode of homelessness, and use of other substances. Specifically, findings of adjusted analyses showed binge drinking, but not daily alcohol use or using alcohol more than twice a week, predicted increased initiation into street prostitution. Likewise, increased risk for initiation into street prostitution was predicted where youth reported use of marijuana or hashish, cocaine, heroin, acid and use of solvents or glues. Effect sizes showing associations between use of these substances and initiation into prostitution were low (range d ¼ 0.06 to d ¼ 0.28) showing a small degree of relationship. Associations between substance use, indicated by aggregate measures of use of various substances, and initiation into prostitution were also investigated in this study. Specifically, drug use (defined as use of at least three different types of drugs), use of drugs more than twice a week, drug bingeing, and intravenous drug use were predictive

of increased risk for initiation into prostitution with generally moderate effect sizes (range d ¼ 0.24 to d ¼ 0.46). Sexual victimization. One study presented findings of analyses examining whether sexual victimization was longitudinally associated with substance use. Distinctively, in their Canadian study, Roy et al. (2007) showed rape and intravenous drug use were longitudinally associated with increased risk for initiation into drug injection in both univariate and multivariate analyses, with small effect sizes (d ¼ 0.22 and d ¼ 0.25, respectively).

Discussion This systematic review is the first of its kind to appraise published studies investigating substance use in its association with the perpetration of sexual offenses, engagement in sexual risk behavior, and experience of sexual victimization. Twentythree studies were identified and reviewed. Findings showed alcohol, marijuana, and stimulants (e.g., amphetamines) were the most commonly reported substances used. Due to variation in the timeframes within which substance use was reported, and disparity in measurement tools, there was considerable inconsistency in rates of substances across reviewed studies. No studies examining substance use in its association with perpetrating sexual offenses were located. Studies examining associations between substance use and experience of sexual victimization were also scarce, with the majority of reviewed studies concentrating on engagement in sexual risk behavior and its association with substance use. Of particular interest in this review were associations between perpetration of sexual offenses, engagement in sexual risk behavior, or experience of sexual victimization, and use of substances among homeless youth. While the findings of reviewed studies generally showed substance use was associated with sexual risk behavior or sexual victimization, it remains unclear whether substance use preceded or followed these behaviors and experiences. Indeed, the findings of some reviewed studies showed statistically significant associations between sexual risk behavior, victimization, and substance use while other studies found no statistically significant associations. Variations in observed findings may relate to lack of power in analyses conducted and low sample sizes. The type of analyses conducted across reviewed studies may also explain the observed discrepancies in study findings, with many reviewed studies conducting multivariate analyses controlling for other possibly relevant variables. It is possible that low sample sizes in conjunction with the number of variables included in multivariate analyses may have impacted power to detect differences in study findings. Nonetheless, the results of this review support recent research (Heerde, Hemphill, & Scholes-Balog, 2014) indicating homeless youth experience various forms of sexual victimization, with rape, sexual assault, and witnessing and fearing the sexual behavior of others the most commonly reported forms. Further, engagement in street prostitution and sex work, survival sex, and trading sex for specific commodities are


16


Risky sexual behavior or victimization predictor (T1)

Survival sex

Sexual risk behavior Weber et al. Binge drinking (2004) Daily alcohol use Drug binge Drug use Marijuana or hash Cocaine, crack or freebase Heroin Heroin and cocaine Acid or phencyclidine Mushrooms Amphetamines Solvents or glues Injection drug usea

Substance use predictor (T1)

Sexual victimization Roy et al. Rape (2007)

Roy et al. (2011)

Sexual risk behavior Roy et al. Survival sex (2007)

Author

Initiation into prostitution

Risky sexual behavior or victimization outcome (T2) Univariate and Multivariate Cox Proportional Hazards Regression

Statistical analysis method

Univariate and Multivariate Cox Proportional Hazards Regression


Initiation into drug injectiona



Statistical analysis method


Substance use outcome (T2)

Binge drinking Increased risk for initiation into prostitution (HR ¼ 1.0, p not stated) Alcohol use (daily use) Decreased risk for initiation into prostitution (HR ¼ .80, p not stated) Alcohol use (more than 2 times/week) Decreased risk for initiation into prostitution (HR ¼ .80, p not stated) Drug binge Increased risk for initiation into prostitution (HR ¼ 2.1, p not stated) Drug use (more than twice a week) Increased risk for initiation into prostitution (HR ¼ 2.7, p not stated) Drug use (at least 3 types of drugs) Increased risk for initiation into prostitution (HR ¼ 2.0, p not stated) Marijuana or hash Increased risk for initiation into prostitution (HR ¼ 1.3, p not stated)

Rape (analytic sample): Increased initiation into drug injection (unadjusted HR ¼ 2.5, p not stated) Increased initiation into drug injection (adjusted HR ¼ 2.8, p not stated) Findings

Rape (analytic sample): Increased initiation into drug injection (unadjusted HR ¼ 2.5, p not stated) Increased initiation into drug injection (adjusted HR ¼ 2.8, p not stated) Survival sex (analytic sample): Increased initiation into drug injection (unadjusted HR ¼ 2.99*) Increased initiation into drug injection (adjusted HR ¼ 3.0, p not stated)

Findings

(continued)

d ¼ 0.06

d ¼ 0.38

d ¼ 0.24

d ¼ 0.18

d ¼ 0.12

d ¼ 0.50

d ¼ 0.00

Effect size

d ¼ 0.25

d ¼ 0.22

d ¼ 0.27

d ¼ 0.26

d ¼ 0.25

d ¼ 0.22

Effect Size

Table 4. Longitudinal Studies Reporting Associations Between Sexual Risk Behavior or Sexual Victimization and Substance Use, and Substance Use and Sexual Risk Behavior or Sexual Victimization.

17


Risky sexual behavior or victimization predictor (T1) Substance use outcome (T2)

Note. T1 ¼ baseline (time 1); T2 ¼ follow-up (time 2); HR ¼ hazard ratio; d ¼ Cohen’s d. a Type of drug(s) comprising the measure not stated. *p < .05.

Author

Table 4. (continued) Statistical analysis method Cocaine, crack or freebase Increased risk for initiation into prostitution (HR ¼ 2.1, p not stated) Heroin Increased risk for initiation into prostitution (HR ¼ 2.9, p not stated) Heroin and cocaine Increased risk for initiation into prostitution (HR ¼ 1.0, p not stated) Acid or phencyclidine Increased risk for initiation into prostitution (HR ¼ 3.2, p not stated) Mushrooms Decreased risk for initiation into prostitution (HR ¼ .7, p not stated) Amphetamines Decreased risk for initiation into prostitution (HR ¼ .5, p not stated) Solvents or glues Increased risk for initiation into prostitution (HR ¼ 2.0, p not stated) Injection drug use Increased risk for initiation into prostitution (HR ¼ 2.7, p not stated) Drug use (more than 2 times/week) Increased risk for initiation into prostitution (AHR ¼ 2.3, p not stated) Injection drug use Increased risk for initiation into prostitution (AHR ¼ 2.2, p not stated) Heroin use Increased risk for initiation into prostitution (AHR ¼ 2.2, p not stated) Acid/phencyclidine Increased risk for initiation into prostitution (AHR ¼ 2.7, p not stated)

Findings

d ¼ 0.55

d ¼ 0.44

d ¼ 0.44

d ¼ 0.46

d ¼ 0.24

d ¼ 0.17

d ¼ 0.17

d ¼ 0.09

d ¼ 0.28

d ¼ 0.00

d ¼ 0.26

d ¼ 0.18

Effect Size

18


commonly described forms of sexual risk behavior. It has been purported that factors associated with experiencing homelessness may be associated with these behaviors and experiences (Heerde, Hemphill, & Scholes-Balog, 2014; Heerde & Hemphill, 2015) such that the situational circumstances encountered by homeless youth and within the lifestyle in which these young people are embedded may contribute to engagement in forms of sexual risk behavior or increase the likelihood of sexual victimization. Importantly, these same situational and lifestyle factors, coupled with both adverse family circumstances prior to entering homelessness and forms of sexual victimization or risk behavior experienced while homeless, may contribute to use of substances among these already vulnerable youth. Literature on childhood and early adolescent experiences of homeless youth commonly show these young people have not received the care and protection to which they are entitled, reporting histories of family violence, child abuse, and a lack of supportive family and peer relationships (Bearsley-Smith et al., 2008; Martijn & Sharpe, 2006). Moreover, homelessness creates further risk and vulnerability for these youth, as they experience a lack of access to money for food or other commodities, a lack of appropriate shelter and clothing, and subcultures of violence (Kennedy & Baron, 1993; Schreck, Wright, & Miller, 2002). While homeless, a young person’s view of self becomes less clearly specified, including social placement in the family, general community, and in relationships with others. Notably, these vulnerabilities and risks require homeless youth to engage in behaviors, such as survival sex, which are not generally considered appropriate within mainstream society. It is probable that these young people may use substances as a means of coping with the trauma associated with victimization in the family environment, re-victimization experienced while homeless, social displacement, and the adoption of behaviors required to ensure daily survival (e.g., sexual risk behaviors). Importantly, none of the reviewed studies examined coping as a covariate in their investigations of associations between substance use and sexual risk behavior or victimization (or vice versa). Use of substances may be an important coping mechanism among these youth to decrease, change, or escape memories of childhood trauma; strains faced while homeless; and trauma and emotional discomfort associated with engagement in sexual risk behaviors or experience of victimization. Although there is limited extant research examining coping among homeless youth, findings of these studies have generally shown substances are used by this population group to manage their feelings, psychological distress, and emotional discomfort (Fisher, Florsheim, & Sheetz, 2005; Kidd, 2003; Rhule-Louie, Bowen, Baer, & Peterson, 2008). There is a need to understand the role using substances may have in relation to sexual risk behavior and sexual victimization. Quantitative investigations which examine how substance use may be related to coping are warranted. Qualitative investigations may also be of benefit in providing a deeper understanding of the experiences of young people while homeless, and importantly the personal, behavioral, social, and health impacts of these experiences. Notably,

the narratives of homeless young people are required in order to contextualize their lived experiences and enable a more authoritative discussion of factors associated with sexual risk behavior, victimization, and substance use. Such research would be particularly useful (1) in relation to whether substance use is a coping mechanism and how substances may be used to change thoughts and emotions linked to engagement in sexual risk behavior and experience of sexual victimization; and (2) how support services may be advanced to improve outcomes for these young people. The findings from such studies may have a critical role in informing understandings of the methods by which youth cope with their homeless experiences, and prevention and intervention approaches aimed to decrease the incidence and severity of substance use, abuse, and dependence amongst homeless youth. There is a need to consider how support from significant adults or community-based support persons (e.g., outreach and social workers) can intervene to assist homeless youth cope with their daily experiences, and both reduce substance use and address health concerns related to engagement in sexual risk behavior or experiences of sexual victimization. It is well documented that immediate and long-term health concerns including mental health problems (e.g., depression, PTSD), trauma, and injury can result from being victimized (including sexual victimization; Barry, Ensign, & Lippek, 2002; Bearsley-Smith et al., 2008) or through engaging in sexual risk behavior. Further, high rates of unprotected intercourse and sexually transmitted infection diagnoses are reported among homeless women (Tevendale, Lightfoot, & Slocum, 2009), while unplanned pregnancy is often the result of survival sex, unprotected intercourse, and sexual assault (Little, Gorman, Dzendoletas, & Moravac, 2007). There is a need to consider the role of supportive adults in reducing the prevalence of these health concerns. For instance, two reviewed studies showed support from adults within a young person’s home environment and parent attachment remained statistically significant for reduced engagement in sexual risk behavior (Stein et al., 2009; Whitbeck et al., 2001). It is possible a lack of assistance from supportive adults may exacerbate the effects of engaging in sexual risk behavior and experiencing sexual victimization. Findings from research examining how supportive adults can intervene to help youth cope with their homeless experiences, reduce engagement in sexual risk behavior, and reduce vulnerability to sexual victimization have the potential to decrease rates of substance use among homeless young people. Such findings also have the potential to contribute to current intervention and prevention efforts designed to address the physical and psychological (including substance use) health concerns of homeless youth, and in particular decrease those adverse health outcomes associated with sexual risk behavior or sexual victimization, as well as substance abuse and dependence. Last, there exists potential for such findings to inform policy recommendations governing health service provision. Over half of all papers appraised in this review either examined associations separately for males and females or included gender as a covariate in analyses conducted. Results showed that associations between substance use and sexual victimization


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were generally stronger for females (Tyler et al., 2004; Whitbeck et al., 2000), as were associations between risky sexual behavior and substance use (Huba et al., 2000; Stein et al., 2009). The results of other studies which examined gender as a covariate were inconsistent, with some studies reporting no statistically significant associations of gender on substance use, sexual victimization, or risky sexual behavior (Roy et al., 2007, 2011; Tyler et al., 2000b, 2001; Walls & Bell, 2011; Whitbeck, Chen, Hoyt, Tyler, & Johnson, 2004). Conversely, other studies found gender (being female) was associated with increased risk for these behaviors and experiences (Tyler et al., 2000b; Unger et al., 1997; Whitbeck et al., 2001). Gender differences in health risks behavior among homeless youth have been acknowledged, with females in comparison to males often reported as experiencing higher levels of drug risk behavior (Montgomery et al., 2002), anxiety (Ritchey, La Gory, & Mullis, 1991), depression, trauma resulting from victimization (Barry et al., 2002; Bearsley-Smith et al., 2008), and sexual risk behaviors (including unprotected sex and sexually transmitted infections; Tevendale et al., 2009). Further investigations examining potential differences in associations between sexual risk behavior, victimization, and substance use are especially warranted. The findings of this review showed a distinct lack of published studies from outside the United States, thus it remains to be seen whether associations between sexual risk behavior and victimization, and substance use, differ as a function of place. Although this review was an investigation of internationally conducted studies, and no restrictions were placed on the country of origin of the publication, only four located studies reported analyses conducted on samples from outside the United States and these were located in Canada. Similar to studies conducted on U.S. samples, findings from each of these Canadian studies reported associations between survival sex and sexual victimization and substance use, and substance use and sexual risk behavior. Therefore, this review is limited in its ability to infer differences in associations between these behaviors and experiences in different countries. Internationally, research is needed to investigate engagement in sexual risk behavior and sexual victimization experienced by homeless youth in their association with substance use. Also particularly scarce were studies examining rates of and specific forms of substance use, sexual victimization, and engagement in sexual risk behavior among subgroups of homeless youth defined by race/ethnicity. For instance, all but two studies (Hayley et al., 2004; Rice, Stein & Milburn, 2008) presented rates of ethnicity breakdown in descriptions of their sample characteristics, with the majority of samples from each study being of White descent (range 28–82%). Across the reviewed studies, only seven examined race as a covariate in their analyses, with results showing inconsistent findings as to the influence of race/ethnicity on substance use, sexual victimization, and/or engagement in sexual risk behavior. Studies investigating the influence of race/ethnicity on associations between substance use sexual risk behaviors, sexual offenses, and sexual victimization are required to gain insight into

whether specific ethnic groups may be particularly at risk and warrant more intensive support and prevention services.

Study Limitations Limitations of the current review. Several limitations of this literature review and the interpretation of the findings are acknowledged. A conservative method of reviewing only those studies that investigated substance use in its association with either the perpetration of sexual offenses, engagement in sexual risk behavior, or experience of sexual victimization were reviewed. It is likely that at least some participants in these studies had engaged in sexual risk behavior and had experienced multiple forms of victimization (e.g., sexual and physical victimization) while homeless. Next, this review was concerned with selfreported perpetration of sexual offenses, sexual victimization, or engagement in sexual risk behaviors, and as such, studies reporting police contact for sexual offenses or arrest for engagement in sexual risk behavior were omitted. It is acknowledged that studies reporting police contact or arrest would be of interest in further research examining source effects. For example, it is possible that self-reported police contact or arrest will show stronger relationships with substance use than arrests recorded in official records. Last, this review focused on peer-reviewed studies; hence, ‘‘gray literature’’ examining the topic was excluded. Limitations of reviewed studies. Some potential limitations to the reviewed studies are noted. First, no studies analyzed associations between substance use and perpetration of sexual offenses, while few studies analyzed associations between substance use and sexual victimization. Next, numerous reviewed studies presented rates for specific substances used, however did not examine associations between the use of these substances and the perpetration of sexual offenses, experience of sexual risk behavior, or victimization. Similarly, where substance use was examined in its association with these behaviors, the reviewed studies typically reported the use of aggregate measures of substance use (e.g., hard drug use or abuse), as opposed to specific substances (e.g., heroin, amphetamines). Only four reviewed studies were longitudinal in design, thus study authors were restricted in their ability to infer that substance use precedes or follows sexual victimization or sexual risk behavior. Disparity also exists in the measurement of substances. For example, time frames including daily, weekly, monthly, and lifetime were used to measure substances used. Likewise, discrepancies were evident in the constructs measuring sexual risk behavior and sexual victimization. For example, some studies examined constructs such as rape or sexual assault, or sex work and prostitution, survival sex, or trading sex, respectively. It is acknowledged that the samples analyzed in some studies were not representative of a unique sample of homeless youth. No studies directly compared associations between substance use and sexual risk behavior or victimization among homeless youth to those within the general population. Studies examining


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differences in associations by gender, race and ethnicity are also warranted. Such studies are required to determine how the function of substance use differs in relation to these behaviors for these subgroups of young people, and how substance use, sexual risk behavior, or sexual victimization may be targeted as modifiable processes by which to reduce the incidences of these behaviors and associated health outcomes. Last, the review findings are restricted by the lack of representation of published studies from outside North America.

Conclusions The present study presents a novel examination of substance use among homeless youth in its association with sexual offenses, sexual risk behavior, and sexual victimization. Studies investigating perpetration of sexual offenses were not located; however, studies of sexual risk behavior and victimization showed homeless youth commonly experience and engage in various forms of sexual victimization and sexual risk behavior, respectively. Substance use was generally associated with sexual risk behavior and sexual victimization; however, it remains unclear whether substance use precedes or follows these behaviors and experiences. It is possible substances are used by homeless youth as a means of coping with sexual risk behavior and victimization. Future research investigating the methods by which youth cope with their homeless experiences is warranted and is likely to inform prevention and intervention approaches aimed to decrease the incidence and severity of health concerns related to sexual risk behavior, sexual victimization, and substance use and abuse among homeless youth. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work of Dr. Heerde is supported by funding provided through the Learning Sciences Institute Australia, at Australian Catholic University.

Supplemental Material The online appendices are available at http://tva.sagepub.com/ supplemental.

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Author Biographies Jessica A. Heerde is a postdoctoral research associate at Australian Catholic University. She is conducting her postdoctoral research on the predictors and outcomes of adolescent health and social behaviors, including marginalized adolescents, to inform prevention and intervention programs leading to improved outcomes for all young people. Sheryl A. Hemphill is a Program Director in the Learning Sciences Institute Australia and Professor of Psychology at Australian Catholic University. She completed her PhD in psychology at La Trobe University, Australia. Her research focuses on the development and prevention of antisocial behavior and related problem behaviors, with a focus on family and school contexts.


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