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Individual and structural vulnerability among female youth who exchange sex for survival Miller, Cari L.; Fielden, Sarah; Tyndall, Mark; Zhang, Ruth; Gibson, Kate; Shannon, Kate Jul 31, 2011

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INDIVIDUAL AND STRUCTURAL VULNERABILITY AMONGFEMALE YOUTH WHO EXCHANGE SEX FOR SURVIVALCL Miller1, SJ Fielden2, MW Tyndall2,3, R Zhang3, K Gibson4, and K Shannon2,31Simon Fraser University, Burnaby, British Columbia, Canada2Faculty of Health Sciences, University of British Columbia, Vancouver, British Columbia, Canada3British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada4Women’s Information Safe Haven (WISH) Drop-In Centre Society, Vancouver, British Columbia,CanadaAbstractPurpose—Because of growing concerns regarding the heightened vulnerabilities and risk ofhuman immunodeficiency virus infection among youth who exchange sex for survival, weinvestigated individual risk patterns and structural barriers among young (≤24 years) female sexworkers (FSWs) in Vancouver, Canada.Methods—Between 2005 and 2008, a total of 255 street-based FSWs (≥14 years) were enrolledinto a community-based prospective cohort, and were asked to participate in baseline and biannualquestionnaires administered through interviews and human immunodeficiency virus screening.We used contingency table analysis to compare individual and structural barrier results obtained atbaseline for younger (≤24 years) FSWs with those of the older (>25 years) FSWs. For longitudinaldata, we used generalized estimating equations throughout the follow-up period to determinefactors associated with being a young FSW in the past 6 months.Results—In comparison with older FSWs (n = 199), youth (n = 56) were more likely to spendfewer years engaging in sex exchange (median: 6.4 [interquartile range: 4.6–9.1] vs. 19.9[interquartile range: 10.0–26.8]; p ≤ .001), belong to an aboriginal ancestry (59% vs. 44%; p = .052), and be homeless (68% vs. 36%; p ≤ .001). In the multivariate generalized estimatingequations analysis, youth reported a significantly elevated proportional odds of being homeless(odds ratio [OR]: 1.26 [confidence interval {CI}: 1.08–1.48]), servicing clients in public places(OR: 1.28 [CI: 1.04–1.57]), injecting heroin on a daily basis (OR: 1.35 [CI: 1.06–1.74]), and asignificantly reduced odds of accessing methadone maintenance therapy (OR: .76 [CI: .62–.93]).Conclusions—This study demonstrates significant displacement of youth who engage in sexexchange to marginalized working and living spaces. The findings of this study bring to attentionthe critical need for targeted structural interventions including access to youth and gender-specificsocial housing, safe working spaces, reduction in the amount of harm caused to them, andaddiction treatment services for youth engaged in survival sex work.Keywordsadolescent; drug treatment; drug users; homeless youth; methadone maintenance therapy;prostitution; substance-related disorders; survival sex work; young adultSend correspondence to: Kate Shannon, [PhD, MPH], B.C. Centre for Excellence in HIV/AIDS, Assistant Professor, Faculty ofMedicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada, Tel:604-806-9459, Fax: (604) 806-9044, gshi@cfenet.ubc.ca.NIH Public AccessAuthor ManuscriptJ Adolesc Health. Author manuscript; available in PMC 2012 July 09.Published in final edited form as:J Adolesc Health. 2011 July ; 49(1): 36–41. doi:10.1016/j.jadohealth.2010.10.003.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript1. INTRODUCTIONGlobally, adolescents and youth under the age of 25 years [1] are an important targetpopulation with respect to public health because of their rapid and multiple transitions intoadulthood, during which sexual and drug vulnerabilities are initiated and health patterns areestablished [2]. Of particular concern is that the number of youth becoming “streetentrenched,” characterized by involvement in the street economy, is growing because offamily fragmentation, which in turn is increasing as a result of conflict, disease,urbanization, and the effects of increasing gaps in income, employment, housing, and foodsecurity [3]. Street-entrenched youth are more likely to have experienced elevated rates ofchildhood neglect and/or abuse, separation from their original families (e.g., foster care), themultigenerational effects of colonization, lack of positive role modeling during early life,and social exclusion (e.g., racial and sexual minorities) [4] and [5]. They also face some ofthe worst health outcomes in society including elevated risk for substance abuse, humanimmunodeficiency virus (HIV), hepatitis C virus (HCV), sexually transmitted infections,and poor access to health services [6].A lack of options for safety and survival often compel vulnerable youth to become involvedin the street economy, often translating to street-level dealing for young men and survivalsex work for young women [7]. Studies have demonstrated that between 14% and 46% ofstreet-entrenched youth exchange sex for money, drugs, shelter, or other commodities as ameans of survival [8]. In a recent cross-sectional study involving youth and adult female sexworkers (FSWs) in two Mexican-U.S. border cities, it was shown that adult women whoinitiated sex work at an earlier age (<18 years) were more likely to use inhalants, use sex topay for alcohol, and report a history of child abuse [9]. Collectively, these studies haveprovided insights into youth vulnerability to survival sex work and factors driving earlyinitiation into it. However, there remains scant prospective evidence among young FSWs,and fewer studies that examine the individual, social, and structural factors that shapeexperiences of exchanging sex for survival among young women when compared with theiradult counterparts. Qualitative and ethnographic studies have demonstrated the gendereddimensions of survival of young women in the street economy that shapes their agency andaccess to resources [10] and [11]. Among women who exchange sex on the street, youth aremore likely to report relying on an older male partner for drugs, requiring assistance withinjecting and being second on the needle, thus compounding their inability to safelynegotiate sexual and drug risk reduction practices [12] and [13].It has been estimated that the average age at which women first initiate survival sex work isbetween 15 and 16 years [14] and [15], and early initiation during adolescence is associatedwith a twofold increased odds of HIV infection in adulthood [16]. Although we cannotdiscount that trafficking of underage women may comprise a small proportion of youthinvolved in sex work in North America, research suggests that the majority of street-entrenched youth become involved in survival sex work for quick money when alternativesfor income and employment security are unavailable [17]. The barriers to accessing socialassistance during adolescence have been further postulated to lead to street-involved youth’sengagement in survival sex work as a means of basic subsistent need [18]. To date,“protecting” youth engaged in survival sex work has been largely left to the criminal justiceand social welfare systems, where youth are either locked up in youth detention centers orrepatriated to families and/or foster homes, which they had left in the first place [18]. Thisapproach has been shown to have the detrimental effect of isolating youth from healthservices [13] and [19]. Given the critical need for research to elucidate policy and servicegaps that are youth-specific and tailored to meet the needs of street-entrenched youth whoexchange sex for survival, we undertook this study to determine individual, social, andMiller et al. Page 2J Adolesc Health. Author manuscript; available in PMC 2012 July 09.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptstructural risk factors associated with younger age (≤24 years) among a prospective cohortof street-based FSWs.METHODSThe community-based HIV prevention research partnership has been described in detailelsewhere [16]. Briefly, a key component of the Maka project is capacity-building amongwomen involved in survival sex work, which is supported by an open community advisoryboard. Between 2006 and 2008, street-based FSWs living in the lower mainland ofVancouver, British Columbia, Canada, were enrolled in an open, prospective cohort andwere asked to participate in an interview-based questionnaire and voluntary HIV screeningat baseline and also at follow-up visits carried out every 6 months. On the basis of previousresearch, which identified 100% substance use among street-based FSWs in Vancouver,eligibility criteria was defined as being female (≥14 years) who used illicit drugs (excludingmarijuana) and exchanged sex for money, drugs, shelter, or other commodities on the streetin the past month. Given the difficulties in accessing a representative sample of FSWsbecause of the unknown size and boundaries of this population, initial mapping of workingareas with >60 FSWs helped identify sex work strolls, which were then used for targetedoutreach and recruitment. Time–space sampling [20] was used to systematically sample allwomen (inclusive of transgender women) working at staggered times and locations alongthese strolls (response rate of 94%). Participants received compensation worth Can $25 atbaseline and each follow-up visit. This study was approved by the University of BritishColumbia’s and Providence Health’s Research Ethics Boards.Study instrumentsAt baseline and follow-up visits, a detailed semi-structured interview-based questionnaireadministered by trained peer researchers (former and/or current FSWs) helped elicitresponses related to sociodemographic factors, health service use, working conditions,violence, and sexual- and drug-related practices. Voluntary HIV screening using the newpoint-of-care rapid INSTI test (Biolytical, Canada, specificity 99.3%, sensitivity 99.6%) wasperformed by the project nurse, which was supported by pre- and post-test counseling. HIV-positive tests were confirmed by Western blot. The health and violence questions wereasked by the registered nurse to facilitate referral to support services.Statistical analysesWe used contingency table analysis to compare baseline sociodemographic and sexual- anddrug-related variables results obtained for younger (≤24 years) FSWs with those of the older(>25 years) FSWs. Chi-square and Fischer’s exact tests, where appropriate, were used tocompare categorical variables between the two groups. Because longitudinal data wereavailable with serial measures for each subject, we used generalized estimating equations(GEE for binary outcomes with logit link for the analysis of correlated data to determinethroughout the 24-month follow-up period the factors that were associated with younger age(≤24 years) in the past 6 months. These methods gave rise to standard errors that wereadjusted by multiple observations per person using an exchangeable correlation structure. Inthis case, participants aged >24 years during the study period then contributed to the olderage category ensuring that any correlations, if found, were attributable to the younger agecategory. Therefore, data from every follow-up visit, among those aged 24 years or younger,were considered in these analyses. For instance, an individual may have reportedexperiencing homelessness during one follow-up period and not another and this analysisapproach serves to examine, throughout the follow-up period, behaviors and characteristicsthat are correlated with younger age both within individuals and between individuals.Although it is unconventional to use age as a dependent variable, this method has been usedMiller et al. Page 3J Adolesc Health. Author manuscript; available in PMC 2012 July 09.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptsuccessfully in previous analyses examining factors associated with younger age in aprospective cohort of individuals who use injection drugs [21].Independent variablesSpecific structural factors collected at baseline and follow-up visits were considered on thebasis of previously published data and a priori hypothesized relationships, includinghomelessness within the last 6 months, access to drug treatment including methadonemaintenance therapy (MMT), place of servicing clients (car or outdoor public spacecompared with indoor settings [e.g., hourly room, sauna]), and street-policing strategies(defined as confiscation of drug use paraphernalia without arrest). Individual variablesconsidered in the analysis included being of aboriginal ancestry (aboriginal vs. non-aboriginal) [32], age of the individual at the time of first exchange of sex for money and/ordrugs, serologically confirmed HIV status at baseline, and consensual unprotected vaginal oranal sex with a primary sex partner or client. Drug use patterns measured included baselinereports of ever having used injection drugs, and similar to previous analyses, longitudinalmeasures for frequent (≥1 per day) use of injection cocaine, heroin, and crystalmethamphetamine as well as frequent crack and noninjection crystal methamphetamine use.Analyses were restricted to only those FSWs who completed a baseline and one follow-upvisit. Variables potentially associated with younger age were examined in bivariate analyses.To adjust for potential confounding, we fit a multivariate logistic GEE model using an apriori defined model building protocol, which adjusted for all variables that were statisticallysignificant at p < .10 in the bivariate analyses. All p values were two-sided and odds ratios(ORs) reported at 95% confidence intervals (CIs).RESULTSA total of 255 women completed a baseline survey (response rate of 94%) and one follow-up visit and were included in this analyses, with 601 observations available over four visits(median visits = 2, interquartile range [IQR]: 1–3). Approximately half (47%, n = 121) ofthe participants have aboriginal ancestry; First nations, Metis, Inuit or non-status FirstNations. The median age at baseline was 36 years (IQR: 25–41) and the median age of sexwork initiation was 15 years (IQR: 13–21). Overall, HIV prevalence at baseline was 23%.Consistent with the United Nations definition of youth (≤24 years), 22% (n = 56) of thepopulation studied were youth (ages: 18–24 years) and 78% (n = 199) were aged ≥25 years.In baseline analysis (Table 1), in comparison with older FSWs, youth engaged in sexexchange for a fewer number of years (median: 6.4 [IQR: 4.6–9.1] vs. 19.9 [IQR: 10.0–26.8]; p ≤ .001) and were less likely to self-report being HCV-positive (43% vs. 70%; p = .001). Youth were more likely to be of aboriginal ancestry (59% vs. 44%; p = .052) and behomeless in the last 6 months (68% vs. 36%; p ≤ .001). There were no statistical differencesat baseline with respect to age at first sex exchange (16 [IQR: 14–19] vs. 17 [IQR: 14–26]),HIV seropositivity (18% vs. 24%; p = .361), and ever injecting drugs (70% vs. 80%; p = .104).In unadjusted GEE analysis (Table 2), youth had a higher proportional odds of injectingheroin frequently (OR: 1.40 [CI: 1.09–1.79]) and using noninjection crystalmethamphetamine frequently (OR: 1.47 [CI: .99–2.18]). They were also significantly morelikely to experience structural barriers of homelessness (OR: 1.27 [CI: 1.08–1.49]), servicingclients in cars and public spaces (OR: 1.30 [CI: 1.05–1.60]), having police confiscate druguse paraphernalia without arrest (OR: 1.20 [CI: .99–1.45]), and were less likely to haveaccess to MMT (OR: .72 [CI: .58–.89]). In our adjusted multivariable model, factors thatremained associated with younger age in longitudinal analysis were homelessness (OR: 1.26Miller et al. Page 4J Adolesc Health. Author manuscript; available in PMC 2012 July 09.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript[CI: 1.08–1.48]), servicing clients in a public place (OR: 1.28 [CI 1.04–1.57]), injectingheroin frequently (OR: 1.35 [CI: 1.06–1.74]), whereas access to MMT was inverselyassociated with younger age (OR: .76 [CI: .62–.93]).DISCUSSIONIn this study, we have found evidence of the increased dislocation of young street-basedFSWs to isolated and outdoor housing and work environments. Furthermore, youth weremore likely to be dependent on heroin, but significantly less likely to access addictiontreatment for opiates as compared with their older counterparts. In combination, thesefindings tell the story of social and structural dislocation among some of the world’s mostvulnerable young women without access to treatment and social support services.Of critical concern, over the 2-year follow-up period in our study, 69% of young FSWsreported “absolute homelessness,” defined as sleeping on the street as compared with 36%of their adult counterparts. In adjusted analyses, after controlling for individual risk factors,youth remained independently more likely to be homeless as compared with adult FSWs.These results suggest that accessible and supportive social housing strategies for femaleyouth are lacking. It has been estimated that between 4% and 7% of youth between the agesof 14 and 26 years are homeless or unstably housed [22]. Homeless youth have higher ratesof infectious diseases, such as hepatitis B, HCV, and HIV, as well as increased risk forpregnancy and violence [5]. Further, as compared with youth who have stable housing, thosewho are homeless report higher rates of injection and noninjection drug use [23]. Morerecently, research has shown that homeless youth and those who are poorly housed (e.g.,shelters, transition houses) are more likely to report inconsistent condom use and multiplesexual partners as compared with stably housed youth [24]. Evidence shows that poorenvironments, such as those created by inaccessibility of safe housing, increase multipleanonymous sexual encounters and reduce the capacity of youth to safely negotiate condomuse [11] and [25]. As such, developing youth and gender-specific supportive housing modelsmay be a critical structural intervention toward engaging young FSWs in social supports,treatment, and health care [11] and [25].Moreover, in addition to living in marginalized public spaces, young FSWs weresignificantly more likely to service clients in public spaces, such as alleys, parkades,industrial settings, and cars, as compared with indoor settings (such as saunas, hourlyhotels). This finding is of particular concern given that we have previously demonstratedthreefold increased odds of coercive unprotected sex by clients and physical violence amongwomen exchanging sex in public spaces and industrial settings [26] and [27]. Theinterrelationships between youth engaged in survival sex work and marginalized work inpublic spaces indicate the multilayered structural barriers for young FSWs. The continuedlegal barriers to client–sex worker date negotiation in public spaces and working in saferindoor spaces seem to have a disproportionately adverse effect on vulnerable youth, thuspushing them outside of the public health and social support umbrella [28]. Importantly,young people must be prioritized within the public health arena by developing supportivepolicing policies to prevent further compromise of young women’s health by virtue ofconfiscation of drug use paraphernalia and increase in the risk for drug use harms throughblood-borne disease transmission. Together these findings support the critical need forsocio-legal policy reforms that remove criminal sanctions targeting sex workers and developsupportive housing and work spaces that facilitate female youth’s control over sexualexchange and also help engage them in public health [8].In addition, youth in this study population were significantly more likely to be dependent oninjection heroin, but significantly less likely to access MMT. Although we have previouslyMiller et al. Page 5J Adolesc Health. Author manuscript; available in PMC 2012 July 09.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptshown elevated rates of heroin injection among youth who inject drugs, the finding ofincreased heroin injection among youth in this sample is of particular concern given that justover half of the entire FSW sample had ever injected drugs [29]. Subsequent research needsto consider how exposure to vulnerable work and living environments shape transitions fromnoninjection to injection drugs and influence access to health care services includingtreatment. It has been postulated that heroin may be a means of coping for young peoplefacing concurrent past and present traumas [30]. Furthermore, the increased likelihood offrequent heroin injection among the youth in this study was most likely fueled by the moreprecarious state of the housing condition of young women and limited access to methadone[31]. In a previous analysis, an unsuccessful attempt to access addiction treatment wasassociated with a twofold increase in the odds of client-perpetrated violence [32]. The needfor tailored and innovative interventions to support young women’s safety, such as low-threshold housing, methadone, and 24-hour safe spaces, will help empower youth to breakthe trauma cycle and afford alternative opportunities to reduce reliance on risky drugs andsexual relationships for survival.Among adults, MMT is a well established harm reduction intervention that assists instabilization and recovery process for those struggling with opioid dependency [33].However, the evidence of this treatment among youth is still ambiguous. A recent qualitativestudy of MMT use among youth indicated its value for treating opioid addiction and theyouth expressed that MMT programs for this age group should be considered a temporarymeasure to assist in the recovery process of young people and be part of a larger morecomprehensive, youth-centered, and holistic approach to addiction treatment [34]. Youngerage most likely adds to complications in accessing MMT services because of providerconcerns over methadone prescription to youth and the absence of specialized serviceproviders for patients aged <19 years. Furthermore, studies on both MMT and socialhousing services for populations that use drugs have highlighted that more effective servicesare operated within a “low-threshold” paradigm and do not exclude clients coping with co-related polysubstance and mental health issues [35] and [36]. Because of the socially andpolitically contentious and difficult nature associated with use of illicit drugs, harmreduction services, and engagement in sexual work by youth, interventionists working withyouth involved in survival sex work who use drugs face challenges in advocating for low-threshold housing, safe spaces, treatment and harm reduction services for this population[37]. However, for young people who find themselves living with addiction, engaged in sexwork, and homeless, there is a striking paucity of resources that address their needs. Furtherevidence is required to elucidate effective and appropriate models of MMT, other drugtreatment strategies, and low-threshold housing and safe spaces to support the health ofyoung women who are socially marginalized.Recognizing the serious vulnerability of young FSWs globally, the United Nations hascalled for an increase in youth-centered participatory interventions that address the causes ofhomelessness and the need for social protection [3]. In recent years, there has been increasedadvocacy for greater meaningful involvement of vulnerable young people to address andcomply with recommendations for “youth-friendly services,” which include componentssuch as equitable and accessible points of delivery; private, non-stigmatizing, and safeenvironments; well-trained and nonjudgmental staff; and youth involvement in assessmentand provision of services [38]. The need to hire and involve young FSWs to develop “rights-based” interventions to reduce the social and structural barriers that create, reinforce, andreproduce risk in this vulnerable population has been underscored [39]. Importantly, in thisstudy, more than half of the young FSWs were of aboriginal ancestry. Therefore, resourcesmust be directed toward aboriginal communities and health authorities should implementaboriginal-centered prevention, treatment, healing, and housing services in urban and ruralMiller et al. Page 6J Adolesc Health. Author manuscript; available in PMC 2012 July 09.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptsettings specifically designed with and for young aboriginal women involved in street-basedsurvival sex work [40].Several limitations to this study must be noted. The observational nature of this research andthe use of self-reported data should be interpreted with caution. However, our use of GEEaccounting for repeated responses by the same person may help to reduce temporality.Importantly, our sample did not comprise young people aged ≤17 years; therefore, the datareflected here may not represent very young populations of women involved in survival sexwork. In addition, our use of age as the dependent variable, although nontraditional,strengthens the associations found with younger age because once the individual aged past24 years, their data contributed to the older age category. The use of self-reported measures,such as violence, rape, childhood sexual and physical abuse, could subject the data toresponse bias. We have tried to minimize this likelihood by using peer trained interviewersand this type of response bias would only serve to underestimate the associations that werefound with these variables. This research provides evidence of the multiple structuralbarriers facing female youth who engage in survival sex work on the streets of cities inCanada. The findings support growing evidence of the critical need to remove legal barriersand to meaningfully engage young FSWs in health and support services. 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Bull WorldHealth Organ. 2009; 87:816–23. [PubMed: 20072766]40. Pearce ME, Christian WM, et al. Cedar Project. The Cedar Project: Historical trauma, sexual abuseand HIV risk among young aboriginal people who use injection and non-injection drugs in twoCanadian cities. Soc Sci Med. 2008; 66:2185–94. [PubMed: 18455054]Miller et al. Page 9J Adolesc Health. Author manuscript; available in PMC 2012 July 09.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptMiller et al. Page 10Table 1Baseline characteristics of women in survival sex work stratified by age ≤24 years and ≥25 yearsCharacteristic ≤24 years n = 56 (22%) ≥25 years n = 199 (78%) p valueYears exchanging sex 6.4 (4.6–9.1)a 19.9 (10.0–26.8)a <.001Median age at which one first exchanged sex for money or drugs 16 (14–19)a 17 (14–26)a .065Self-identify as aboriginal 33 (59%) 88 (44%) .052Homeless (last 6 months) 38 (68%) 72 (36%) <.001HIV positive (HIV screening) 10 (18%) 47 (24%) .361HCV positive (self-reported status) 19 (43%) 124 (70%) .001Ever injected drugs 39 (70%) 159 (80%) .104aMedians (interquartile range) are shown in first two rows, whereas number of participants (percentage positive responses within each category)are shown in remaining rows.J Adolesc Health. Author manuscript; available in PMC 2012 July 09.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptMiller et al. Page 11Table 2Unadjusted and adjusted GEE analyses of factors associated with being a young woman (≤24 years) engagedin survival sexCharacteristic Unadjusted OR (95% CI) Adjusted ORa (95% CI)Individual factors Aboriginal ethnicity 1.70 (.94–3.10) – Inject cocaine frequently .92 (.74–1.14) – Inject heroin frequently 1.40 (1.09–1.79) 1.35 (1.06–1.74) Inject crystal methamphetamine frequently 1.43 (.87–2.35) – Crack cocaine smoking frequently .81 (.65–1.00) – Crystal methamphetamine use frequently 1.47 (.99–2.18) – Unprotected sex with primary partner 1.00 (.86–1.17) –Structural factors Homelessness 1.27 (1.08–1.49) 1.26 (1.07–1.48) Police confiscated drug use paraphernalia (without arrest) 1.20 (.99–1.45) 1.14 (.96–1.36) Service clients in cars and public spaces (alleys, parks) 1.30 (1.05–1.60) 1.28 (1.04–1.57) Inpatient drug treatment 1.09 (.89–1.33) – Methadone treatment .72 (.58–.89) .76 (.62–.93)GEE = generalized estimating equations.aVariables significant at p < .01 entered into multivariate model; adjusted ORs refer to variables significant at p < .05.J Adolesc Health. Author manuscript; available in PMC 2012 July 09.

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