Substance use and risky sexual behavior among homeless and runaway youth

Purpose: To (a) characterize human immunodeficiency virus (HIV)-related risk behaviors of homeless youth; (b) determine whether substance use is associated with risky sexual behavior in this population; and, if so, (c) explore explanations for this relationship.

Methods: A purposive sample of 327 homeless youth (ages 14–21 years) in Washington, DC, were surveyed in 1995 and 1996. Survey items were adapted from items used in a national study of adult substance use and sexual behavior and measured global (lifetime) and event-specific (most recent sexual encounter) behaviors.

Results: Sexual activity with many partners, “survival” sex, and substance use were common. However, needle use was rare, and consistent condom use was evident in half the sample. Nearly all correlations between global measures of substance use and risky sex were statistically significant, but only a few of the event-specific correlations were significant. Marijuana use during the most recent sexual encounter was associated with nonuse of condoms, but this relationship disappeared in the multivariate model. However, crack use during the last encounter was associated with condom use; this relationship remained significant in the multivariate model. Lack of motivation to use condoms, longer histories of sexual activity and homelessness, symptoms of drug dependency, not discussing HIV risks with partner, and being female were also associated with nonuse of condoms.

Conclusions: Homeless youth do use condoms, even within the context of substance use and casual sex. Results suggest that prevention and targeted intervention efforts have had some positive effect on this population, but young homeless women are in need of targeted prevention. Finally, additional research is needed to investigate the observed relationship between crack use and condom use in this sample.     

Substance use and other factors associated with risky sexual behavior among pregnant adolescents.

A study of the relationship between substance use and risky sexual behavior was conducted among 241 unmarried pregnant adolescents aged 17 and younger who lived in a metropolitan area in the Northwest. The respondents had comparable or higher lifetime use rates for all substances than did women in a national sample of high school seniors, even though the pregnant adolescents were younger. Ninety-four percent had used alcohol, 78% marijuana, 30% cocaine and 30% stimulants, compared with 92%, 48%, 14% and 23%, respectively, among women in the national sample. Among the pregnant adolescents, 84% had had more than one sexual partner, 39% had had a sexually transmitted disease and 60% had used contraceptives during less than half of their sexual encounters. At the bivariate level, use of cigarettes and alcohol in general and use of alcohol and drugs during sex were positively associated with risky sexual behavior. However, when other characteristics associated with risky sexual behavior--family bonding, parental monitoring, commitment to conventional values, peer associations, self-esteem and delinquent activities--were included in the multivariate analysis, the effect of substance use disappeared.     

Personal values and sexual decision-making among virginal and sexually experienced urban adolescent girls.

PURPOSE: To guide the development of an intervention to reduce the incidence of sexually transmitted diseases (STDs) in urban, adolescent girls, we investigated such girls' reasons for deciding to have or not to have sexual intercourse. METHODS: Consecutive girls >or=14 years of age attending an urban adolescent clinic were invited to complete an anonymous survey about sexual decision-making. In this pilot study, girls were asked: (a) whether they agreed with a statement that they had or had not had sexual intercourse "because of my values and beliefs"; and (b) to select from a list one or more specific reasons why they had or had not had intercourse. The girls were categorized by self-report as either "virgins," "currently inactive" (no intercourse in the preceding 3 months), or "currently active" (had intercourse during the preceding 3 months). RESULTS: Usable surveys were obtained from 197 adolescents whose age (18.2 +/- 2.6 years) and race (69% black) were comparable to those of clinic attendees in general. Forty girls (20%; age 16.1 +/- 2.1 years) were virgins, 25 girls (13%; age 17.8 +/- 2.3 years) were inactive, and 132 girls (67%; age 18.9 +/- 2.5 years) were currently active. "Values and beliefs" were cited as the reason for decisions about sexual behavior by 53% of the virgins, but only by 24% of the sexually inactive and 24% of the sexually active girls (p = .002). Virgins were more likely than inactive girls to cite three specific reasons for not having sex: "not the right thing for me now" (82% vs. 50%, p = .007), "waiting until I am older" (69% vs. 8%, p = .001), and "waiting until I am married" (67% vs. 38%, p = .02). The reason "against my religious beliefs" was cited by 23% of virgins and 13% of inactive girls (p = not significant). Personal values were implicit in the two specific reasons for having sex that active girls chose most frequently, namely, "I like/love the person" (86%) and "I like having sex" (37%), although only 24% of these girls had explicitly cited "values and beliefs" as their reason for having sex. CONCLUSIONS: Our data indicate that urban girls, both those who have had sexual intercourse and those who have not, view their sexual behavior as being based on personal (although infrequently religious) values. Many of the virginal urban, adolescent girls we surveyed hold abstinence as a personal value. The sexually active adolescents perceive the decision to have sexual intercourse as being based affirmatively on their personal values rather than on the chance occurrence of opportunities to have intercourse. These data may be useful in the development of new strategies for reducing urban adolescent girls' risk of acquiring sexually transmitted diseases.     

Substance use and weight loss tactics among middle school youth

OBJECTIVE: Diet pills (DP) and vomiting or laxative (VL) use as weight loss tactics are associated with substance use in older adolescent populations. This study examined the association of weight loss tactics and substance use among middle school students. METHODS: A Youth Risk Behavior Survey was administered to 6,957 middle school students in eastern North Carolina. Multiple logistic regression examined substance use as predictors of DP and VL use. RESULTS: DP and VL use was reported by 6.0% and 7.1% of students, respectively, with each reported more frequently by females and White students. Regression analysis demonstrated alcohol, cigarette, or marijuana use as predictors for individual race/gender groups whereas steroid use was a predictor for all race/gender groups. We found a clustering effect of alcohol and cigarette use with both DP and VL use. DISCUSSION: Substance use is associated with weight loss tactics as early as middle school. More research in the areas of clustering of behaviors and age at onset is needed.     

Substance use among runaway and homeless youth in three national samples.

OBJECTIVES: Standardized estimates of the prevalence of substance use by runaway and homeless youth between the ages of 12 and 21 in various settings were compared with each other and with estimates for youth in the general population. METHODS: Four surveys were used: (1) a nationally representative survey of runaway and homeless youth residing in federally and non-federally funded shelters; (2) a multicity survey of street youth; (3) a nationally representative household survey of youth with and without recent runaway and homeless experiences; and (4) a nationally representative household survey of youth whose previous runaway/homeless status was unknown. RESULTS: For almost every substance, substance use prevalence was highest among street youth. Shelter youth and household youth with recent runaway/homeless experiences reported similar rates. In the household surveys, substance use rates were lowest and were generally comparable. CONCLUSIONS: Many homeless and runaway youth use tobacco, alcohol, and other drugs at rates substantially higher than nonrunaway and nonhomeless youth, indicating a need for comprehensive and intensive substance abuse prevention and treatment services for these youth.     

Khat and alcohol use and risky sex behaviour among in-school and out-of-school youth in Ethiopia

Background  

Khat (an evergreen plant with amphetamine-like properties) and alcohol are widely consumed among the youth of Ethiopia. However, their relationship to risky sexual behaviour is not well described. This study was conducted to describe the magnitude of risky sexual behaviour (unprotected sex and early initiation of sexual activity) and its association with Khat and alcohol consumption in Ethiopian youths.     

Social and emotional consequences of refraining from sexual activity among sexually experienced and inexperienced youths in California

Objectives. We examined the social and emotional consequences among adolescents of refraining from sexual activity (oral or vaginal sex) and whether these consequences differed over time and by gender and sexual experience.Methods. Adolescents (N=612; 58% female) recruited from 2 schools were assessed at 4 time points separated by 6-month intervals, beginning in fall of ninth grade.Results. The percentage of adolescents who reported only positive consequences (e.g., they felt responsible, friends were proud) dramatically decreased over time, whereas the percentage that reported negative consequences (e.g., they felt left out, partners became angry) steadily increased. Adolescent girls and sexually experienced adolescents were more likely to report both positive and negative consequences than were adolescent boys and sexually inexperienced adolescents. Adolescents who began the study with sexual experience were more likely to report positive consequences of refraining from sexual activity by the end of the study than those who initiated sexual activity later.Conclusions. Sexual education programs should address how adolescents can cope with or prevent negative consequences of refraining from sexual activity, so that decisions to abstain are rewarding and decisions to engage in sexual activity are motivated by maturity and readiness.Numerous prevention efforts are aimed at convincing adolescents to abstain from or delay the onset of sexual behavior.1^,2 These efforts are motivated, in part, by research that has shown that the early initiation of sexual behavior is associated with greater sexual risk taking and related health outcomes among adolescents, including having a greater number of lifetime sexual partners, being under the influence of alcohol or other substances during the most recent sexual experience, experiencing an unintended pregnancy, and contracting a sexually transmitted infection.3^,4 Bearman and Bruckner estimated that more than 2.5 million adolescents had taken public “virginity” pledges to abstain from sexual activity until marriage,5 yet such pledges have been hard for adolescents to keep. For example, data from the National Longitudinal Survey of Youth (Add Health) showed that roughly half of adolescents who pledged to refrain from sexual behavior still initiated it during high school.6Clearly, it is not easy for adolescents to refrain from sexual activity. It is normal for adolescents to experience sexual desire.7 Adolescents face continual choices about whether to engage in sexual activity, and as with all choices, each course of action may have potential positive and negative consequences.8 Although previous research has examined the positive and negative consequences that adolescents perceive will occur or that they actually experienced after engaging in sexual activity,9^–16 little research has examined the consequences of refraining from sexual activity. This research is critical to understanding why adolescents choose a given course of action with respect to sexual activity and whether they maintain this choice over time.Traditional health models developed to explain adult risk behavior, such as the Theory of Planned Behavior,17 Health Belief Model,18 Protection Motivation Theory,19 and Stages of Change Model,20 have considered both positive and negative consequences of health behavior. However, when applied to adolescent sexual behavior, empirical tests of these models as well as intervention efforts tend to emphasize the negative health consequences of sexual behavior (e.g., sexually transmitted infections). Halpern-Felsher et al.11^,21 have argued that it is equally important to consider social and emotional consequences,9^–12 including positive consequences, of sexual behavior.9^,10^,12^,16Positive and negative consequences of engaging in sexual activity represent only half of the equation with respect to sexual decision-making. Adolescents’ experience of positive and negative consequences of refraining from sexual activity is also of conceptual importance in understanding choices adolescents make about sexual activity, yet, surprisingly, no quantitative research has examined adolescents’ experienced consequences of refraining from sexual activity. Some research has examined the motivations adolescents have for refraining from sexual activity. These studies have concentrated on fear-based concerns (e.g., pregnancy) and value-based concerns (e.g., religious edicts against premarital sexual activity).22^,23In a study by Michels et al., which employed qualitative interviews of sexually experienced and inexperienced adolescents, social and emotional concerns (e.g., disappointing one’s family by engaging in sexual activity) were discussed by adolescents who chose not to engage in sexual activity.11 At least 1 qualitative study has examined adolescents’ perceived consequences of refraining from sexual activity, including positive consequences (e.g., protecting one’s reputation) and negative consequences (e.g., being ashamed of one’s virginity).24 The authors did not assess whether consequences had been experienced by participants as a result of refraining from sexual activity, however.Estimates of negative social and emotional consequences of refraining from sexual activity (e.g., they felt left out, partners became angry) among adolescent populations are important to identify, because they may increase the likelihood that adolescents will consider engagement in sexual behaviors with which they might initially have felt uncomfortable. Negative consequences of refraining from sexual activity are of particular importance if they occur at higher rates than do positive consequences.Certain subgroups of adolescents may be at particular risk for experiencing negative consequences of refraining from sexual activity. As they age, adolescents may be more likely to experience negative social and emotional consequences of refraining from sexual activity, because the percentage of their peers who are sexually experienced increases over time.25 Similarly, adolescents who have previously engaged in sexual activity may be at risk for experiencing negative consequences, because they may experience greater external and internal pressures to continue engaging in sexual activity. It is unclear whether aging and previous sexual experience might be associated with adolescents’ reports of positive consequences of refraining from sexual activity.Gender is another factor that may influence consequences. Girls may be more likely than boys to experience both positive and negative consequences of refraining from sexual behavior, because they are more likely than are boys to encounter societal pressures to restrict sexual behavior,24^,26 yet may also experience more overt pressure to engage in sexual activity from opposite-sex partners.24^,27 Because boys’ sexuality and sexual behavior is generally accepted26 and they appear to experience less overt pressure to engage in sexual activity from opposite-sex partners,24^,27 boys may be less likely than girls to experience positive and negative consequences of refraining from sexual activity.We examined the consequences of refraining from sexual activity among a sample of adolescents followed throughout the ninth and 10th grades. We sought to determine (1) the extent to which adolescents experienced positive and negative consequences of refraining from sexual activity, and (2) whether social and emotional consequences of refraining from sexual activity differed over time and by gender and sexual experience.     

Risky groups,risky behaviour,and risky persons: Dominating discourses on youth sexual health

Significant public health attention has been focused on the problems of youth sexual behaviour. Empirical public health research in this area has attempted to account for mostly negative sexual health outcomes (e.g. sexually transmitted infections and teenage pregnancies) by examining individual characteristics and risk-taking behaviour. Public health practice has followed suit, focusing primarily on modifying sexual risk behaviour and lifestyle ‘choices’. In doing so, we may be unwittingly committed to an unarticulated and unrealistic set of assumptions about the level of agency and control that is afforded to many young people. The purpose of this paper is to begin to ‘unpack’ the underpinnings to conventional approaches to public health research and service provision related to youth sexual health in Canada. Drawing on the works of Foucault to show how discourses concerning risky groups, risky behaviour and risky persons have been advanced as sanctioned discourses in Canada (particularly related to HIV/AIDS risk), the authors investigate how themes of safety and goodness have been privileged as healthy, while other, unauthorized forms of youth sexual behaviour have been marginalized. The issue of teen parenthood is examined to demonstrate how these specific discourses have helped to relegate those youth who do not or cannot implant themselves in an ‘approved reality’ to live separately from the norm in a climate of sex-based shame. Drawing on their previous work and that of others, the authors suggest an alternative approach to understanding youth sexual health, one that favours critical, reflexive public health practices and attends to sociological theory.     

Ghanaian youth and festive transvestism

‘Festive transvestism’ is an increasingly visible cross-dressing practice performed by young people in the Southern parts of contemporary Ghana. Based on participant observation in four cross-dressing events, 15 individual interviews and a focus-group discussion, festive cross-dressing is understood as a contemporary ritual that mainly serves the purpose of reinforcing and reproducing gender binaries as well as heteronormativity in Ghanaian society. Nevertheless cross-dressing events also provide a subjective, creative and exploratory space – although temporary and circumscribed – for the transvestites as well as for the spectators to deconstruct sex, gender and sexuality through the performativity of transvestism. The opening of this exploratory space is made possible by the liminality of the social category of youth in Ghana, which grants young people, especially young men, more liberty and (gender) flexibility. Finally, the paper challenges the widely spread Western perception that feminine men and cross-dressers are necessarily homosexual by resituating the concept of homosexuality within the context of Ghanaian society, where it has recently started to occupy the public space.     

Cross-national study of risky sexual behavior among gang-involved youth in metropolitan Boston and San Salvador,El Salvador

Although conformity to peer norms poses significant risks for adolescent sexual behavior, information is limited on types of gang-related activities that predict risky sexual behavior among gang-involved youth. Using data from Boston (n?=?375) and San Salvador (n?=?207), we compared the two groups on key characteristics and assessed factors associated with risky sexual behaviors. Number of arrests and aggression predicted number of sexual partners in Boston and San Salvador samples, while delinquency, arrests and age predicted pregnancy outcomes. Medium to large effect-size differences were noted in future orientation, delinquency and gang-involvement attitudes. Gang-involvement and risky sexual behavior were associated in this sample. Salvadoran youth differed significantly from those in Boston on key gang-related characteristics, rendering them even more vulnerable.     

Substance abuse among sexually abused adolescents and their families

The concurrence of substance abuse and history of sexual abuse among adolescents has prompted this study of substance abuse patterns among families of adolescents who report incest or extrafamilial sexual abuse. A total of 3,179 ninth-grade students in a rural midwestern state completed a survey that included questions about individual and family substance abuse. Adolescents who had been sexually abused were more likely to report substance abuse for themselves as well as for members of their immediate families. They were also more likely to report that they used substances because of family problems, school problems, and because they were sad, lonely, or angry. Adolescents reporting a parent with an alcohol or a drug problem were more likely to use cigarettes, marijuana, alcohol, or “speed.” Adolescents experiencing extrafamilial abuse reported more alcohol abuse and more alcohol-related problems than those who experienced incest. There were similar reports of parental and familial alcohol and drug problems among those experiencing incest and those experiencing extrafamilial abuse. Those with drug-abusing parents, however, were most likely to report some kind of sexual abuse history.     

Reducing risky sexual behavior and substance use among currently and formerly homeless adults living with HIV

Objectives. We examined the efficacy of the Healthy Living Program in reducing risky sexual behavior and substance use among adults with HIV infection who were marginally housed (i.e., homeless at some point over a 37-month period).Methods. We had previously conducted a randomized controlled trial with 936 adults living with HIV infection. In that study, 3 intervention modules of 5 sessions each addressed different goals: reducing risky sexual acts and drug use, improving the quality of life, and adhering to healthful behaviors. Participants were interviewed at baseline and at 5, 10, 15, 20, and 25 months; 746 completed 4 or more assessments. In this study, we analyzed sexual behavior and drug use outcomes for the 35% (n = 270 of 767) of participants who were considered marginally housed.Results. Among the marginally housed participants, there were significantly greater reductions in unprotected risky sexual acts, the number of sexual partners of HIV negative or unknown serostatus, alcohol or marijuana use, and hard drug use among the intervention group than among the control group.Conclusions. Intensive, skill-focused intervention programs may improve the lives of marginally housed adults living with HIV infection.The rate of HIV infection among homeless adults in the United States ranges between 10.5% and 21%,^1–3 a rate 20 to 40 times higher than that among nonhomeless adults. Risky sexual acts are often associated with alcohol and drug use among the homeless, as they are among housed adults.^4–7 Injection drug users who are marginally housed (i.e., homeless at some time during the past 37 months) use shooting galleries and perform sex work twice as often as stably housed injection drug users.⁷ Given these heightened risks, it is critical that HIV-positive homeless and marginally housed adults receive interventions to reduce HIV transmission.Efficacious HIV prevention programs are available for homeless persons of unknown serostatus^8–12; however, no program has targeted adults living with HIV. Building on other prevention programs for HIV-positive persons^13–16 and informed by extensive preliminary qualitative work,¹⁷ the National Institute of Mental Health''s Healthy Living Project was designed for adults living with HIV infection who continued to engage in risky sexual acts after learning their serostatus.¹⁸ In previous analyses of this intervention, exposure to the Healthy Living Project helped adults living with HIV to significantly reduce their numbers of HIV-negative partners or partners of unknown serostatus, increase their condom use, and reduce substance abuse.^19,20 We analyzed the impact of the Healthy Living Project on a subsample of marginally housed adults living with HIV.Surviving while homeless is an all-consuming process, and the resources available to alter habitual sexual and drug behaviors are scarce. Under these stressful conditions, it was unclear whether a behavioral intervention would influence the daily routines of those without stable housing.We defined study participants who were homeless at any point over a period of 37 months as being marginally housed. Longitudinal studies have recently demonstrated that homelessness is usually sporadic.^7,21 In our study, the participants moved in and out of homelessness; only 4 of them remained homeless over the course of the entire study. The primary transmission behaviors examined were risky sexual behavior and drug use.     

Increases in oral and anal sexual exposure among youth attending sexually transmitted diseases clinics in Baltimore, Maryland

We examined reports of receptive oral or anal sex among clinic patients aged 12-25 years over time. Odds of reporting oral sex were approximately three times higher in 2004 than in 1994; odds of anal sex were twice as high. Providers should be aware of increased risk behavior among young people.     

Substance use, sexual intercourse, and condom nonuse among depressed adolescents and young adults

PurposeTo examine daily- and event-level associations of substance use with occurrence of sex and condom nonuse among depressed youth.MethodsDepressed, sexually active outpatients aged 15–22 years reported alcohol use, marijuana use, and sex on a personal digital assistant for 2 weeks. If they reported sex, participants indicated partner type and condom use. Data were analyzed for participants who reported both substance use and sex events (N = 39) using generalized estimating equations. Daily-level models compared the likelihood of sex and of condom nonuse between days on which participants did or did not use substances. Event-level models examined the likelihood of sex in the 2, 6, and 12 hours after substance use and the likelihood of condom nonuse if substances were used in the preceding 2, 6, and 12 hours.ResultsParticipants reported 307 sex events (180 unprotected) and 391 substance use events on 572 days. Substance use was associated with increased odds of sex on the same day, but not after adjusting for weekend. Depressed youth were less likely to have sex within 2 hours after substance use and more likely to have sex within 12 hours after marijuana use. There was no main effect of substance use on condom nonuse; however, there was a significant interaction such that on weekdays, condom nonuse was less likely when substances were used within 6 hours before sex.ConclusionsThe findings from this small, predominantly female sample suggest that contextual factors, not intoxication, influence associations of substance use with sexual behavior in depressed youth.     

Infrequency of sexually transmitted disease screening among sexually experienced U.S. female adolescents

CONTEXT: Since 1993, the Centers for Disease Control and Prevention and professional medical organizations have recommended that all sexually experienced female adolescents receive annual screening for Chlamydia trachomatis. Whether adolescents receive this care is largely unknown. METHODS: Reports of receipt of testing or treatment for a sexually transmitted disease (STD) in the past year, as well as sites of care, were obtained from 3,987 sexually experienced females in grades 7-12 who participated in Wave 1 of the National Longitudinal Study of Adolescent Health, conducted in 1995. Logistic regression was used to determine predictors of reporting care. RESULTS: Eighteen percent of all participants reported having received STD services in the past year. Of those who reported having had a routine physical examination in the past year, 22% reported receipt of STD services. The proportion reporting STD care increased linearly with age from 9% of 12-13-year-olds to 25% of those 19 or older. In adjusted analyses, the odds of reporting testing or treatment were elevated among participants who had had a physical examination in the past year (odds ratio, 2.1), those with Medicaid or Medicare insurance (1.9), black women (1.5) and older adolescents (1.2). Adolescents most often reported having received STD care at a community health center (44%) or a private physician's office (31%). CONCLUSIONS: Continued inadequate screening may contribute to persisting high prevalence of chlamydia infection among adolescents. Future research is needed to determine whether the proportions of adolescents receiving recommended STD screening have increased over time.     

Substance use,gender inequity,violence and sexual risk among couples in Cape Town

Alcohol and other drug use, gender power inequities and violence are key contributors to sexual risks for HIV among South African men and women. Little is known about the intersection between these sex-risk behaviours among couples in established heterosexual relationships. We conducted 10 focus-group discussions with men and women in relationships of 1 year or longer recruited from shebeens (informal taverns) in Cape Town, South Africa. Participants described: high levels of alcohol consumption at shebeens; low levels of condom use with main and casual sex partners; gender roles disfavouring women's condom negotiating power that also promoted economic dependency on male partners; men often spending a portion of the household income on alcohol and other drugs and sex with others in shebeens; loss of household income driving women to trade sex to provide for their families; and sexual violence and the exploitation of women occurring in shebeens. Findings highlight how the social contexts of alcohol and other drug use, gender inequitable norms and gender violence promote HIV risk within established heterosexual relationships in South African communities. Evidence of this kind should inform the design of HIV-risk-reduction interventions tailored to heterosexual couples who drink alcohol in shebeens.