M.F.C.C., Ph.D.,








All initial visits (n = 620) of runaway/homeless youths to an outpatient medical clinic over a PBmonth period cj’uly 198~June 1989) were analyzed. Of these visits. 467 made by youth not involved in prostitution wer, dam_. .pared with 153 visits by youth who were involved. According to the data from an adolescent fisk profile interview, homeless youth involved in prostitution are at greater risk for a wide variety c~fmedical problems and health-compromising behaviors, including drug abuse, suicide, and depression. The implications for public health and social policy are discussed. e-f ‘&‘jL?_j?S : Adolescents Homeless youth Prostitution Psychosocial assessment

Runaway youth

National estimates of youth involved in prostitution range from 90,000 to 900,000 (1). Visualizations of teen prostitr:tes typically conjure up the image of a 16-year-old @l,, dressed to look older, standing on a street corner soliciting. But teen prostitutes are also girls and boys who 1) receive lodging, food, and clothes from men in exchange for sexual favors; 2)

~_Front the Divisionof Adolescent Mediciw (G.L.Y., R.G.M., J.P., A.S.), Childrens Hospital of Los Angeles, and the Department of PL-

diatrics ~G.Z.~?vf.,R.G.M.! and .Medicine !R.G.MJ, University cj Southern Cal$cmia, Los Angeles, California. Address rqwint requests to: CC:Y L. Yates, M.A., M.F.C.C., Division of Ad& scent Medicine, Chxldrens Hospital of Los Angeles, P.O. Box 54700, Los Aqqeles, CA 90054. Manuscript accepted November 20, 1990.



work in bars as dancers, waitresses, or waiters serving sex with drinks for a price; 3) get caught up in pornographic films and photography; and 4) are forced by pimps (soinetimes their parents) to perform sex fur money. Adolescent males do not usually work for pimps, but callboy networks flourish in many cities. Many studies indicate that both male and female youths invoived m prostitution come from dysfunctional families and are victims of sexual abuse as children. For example, SiBbert and Pines (2) found that 60% of the females they studied who were involved in prostituticn had been sexuaiiy abused, and James and Meyerding (3) tound that 86% of their sample of male prostitutes in Boston had a sexual abuse history. Runaway/homeless youth make up approximately 75% of all youth involved in prostitution (1). run away return home Althotigh most youth b~TLO after a brief petiod, those who do not return make up the majority of youth involved in prostitution (2). Runaway youth who become involved in prostitution do not run far from home. One study showed that 5,8% of these adolescents came irom the city they lived i.n or the surrounding area (4). ?Ipose yo:iths who do end u;’ iiving on the zreeis have poor school performance records and high drop-out rates (5). Consequently, they have few marketable job skills for legitimate occupations, and turn to prostitution as a means of surviving on the streets. In one study, 89% of youth involved in prostitution said they became involved because they needed money to survive (2) (heuce thle term “survival sex’” to describe involvement in juvenile pros-

6 Societyfor Adolescent Medicine. 1991 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Ameacas.

545 New York, NY IMllll





Table 1. Demograpk Comparisons of Yourns Invoivei (n = 153) and Not Involved (n : 467) in Prostitution q


Involved (%)

Not involved (%) -

68 32

53 :i7

3 18 65 12 2 -

3 25 46 22 2 2

6 52 “6 6

15 65 17 4

9 31 20 38 2

18 41 12 24 5


Female Male Race Asian Black White Hispanic Native American Other Age (years) lo-14 15-17 18-21 22-24 Origin Local LA County Other California Other state Other country

June 1989. Physicians in training (residents, fellows, and medical students) at the Division of Adolescent Medicine, Childrens Hospital of Los Angeles, conducted examinations and interviews using a psychosocial risk assessment interview instrument that covered six significant areas of inquiry: home, education, activities, drug use and abuse, sexual behavior, suicidality and depression, and satanic ritual involvement. (See Cohen & MacKenzie, this issue.) Data were recorded on the Standardized Adolescent Risk Profile summary data sheet.



titution). The involvement usually takes time to develop; Boyer and James (6) discuss a three-phase come fully assimiprocess during which youth lated into a street subculture that includes prostitution. The effects of sexual exploitation are severe. Youths are at big!- risk for being physically as saulted. They are also at high risk for coming into contact with various sexually transmitted diseases, including human immunodeficiency virus (HIV). Many of them have substance abuse problems (7). In this article, we look at the overall health status of a sample of homeless youths involved in prostitution and compare this with the health status of homeless youths not involved in prostitution.

Methods Since July 1982, the Division cf Adolescent Medicine, Childrens Hospital of Los Angeles, and the Los Angeles Free Clinic have been operating an outpatient clinic for youth between the ages of 12 and 24 years in the Hollywood-Wilshire Health District. As many as 60% of patient visits to the clinic are by runaway/homeless youths. The data in this study were collected at this clinic between July 1988 and

The subjects interviewed and examined for this study included all 620 self-identified homeless youth who made initial visits to the clinic between July 1988 and June 1989. Of these youth, 153 (25%) revealed to their health care providers that they were involved in prostitution at the time of visit. The 467 noninvolved adolescents also attended the clinic during the same period. Youths involved in prostitution were more likely to be female, older, and Caucasian than those not involved (Table 1). The majority of youths involved in prostitution came from outside Los Angeles County,. and 40.1% from outside California. Involved youth comprised only 25% of the population we studied, but accounted for 37% of the recorded medical diagnoses (Table 2). As each patient can have up to 6 diagnoses recorded, most of

Table 2. Medical Diagnoses of Youths Involved (n = 153) and Not Involved (n = 4671in Prostitution Diagnoses”

Involved (%I

Not involved f%)

Sexually transmitted disease Pelvic inflammatory disease Pregnancy Uncontrolled asthma Infectious disease Dermatology problems Family planning services Drug abuse Trauma Rape HIVbrisk

19.0 5.8 18.3 2.6 13.1 5.9 23.1 74.5 3.3 2.6 100.0

9.9 0.4 6.5 1.5 9.4 7.1 30.9 36.0 4.5 0.9 7.7

“Patients were given as many as six diagnoses; approximately 300 different diagnostic categories were available to clinicians. This table represents only a portion of all diagnoses given; percentages will not equal 100%. “HIV, human immunodeficiency virus.


the involved youths were diagnosed as having multiple health problems, with an average of 4.1 diagnoses per youth. A diagnosis relating to sexual activity tended to be more common in the involved group; a diagnosis of pelvic inflammatory disease was more than 14 times as likely in this group. A diagnosis of rape was nearly 3 times as likely to be given to a youth involved in prostitution; diagnoses such as infectious disease and uncontrolled asthma were found more often in involved youth than in their noninvolved peers. More than 74% of the involved group were diagnosed as abusing drugs or alcohol. In Table 3 we report the data gathered by clinicians during the interviews. Involved youth are less likely to be sheltered in relatives’ homes, less likely to be in a shelter, and more likely to live with unrelated roommates. We know from descriptive data solicited during the inferviews that many of the roommate arrangements require sexual favors in lieu of rent. one-quarter of the youth involved in prostitution state that they live on the streets. Involved youth are more likely to have dropped out of school, but a small percentage have gone on to community college or trade schools. There are no significant activity differences between the two groups, but it is interesting to note that more of the involved youth have jobs. Compared to other homeless youth, those involved in prostitution are only slightly more likely to be depressed, but they are twice as likely to have a serious mental health problem (thought disorder, personality disorder). They are almost twice as likely to be actively suicidal or to have previously attempted suicide. As for a difference in drug use, almost all (97%) of the involved youth use drugs or alcohol, compared with 78% of their homeless but noninvolved peers. Nearly 22% of the involved youth used intravenous drugs in the

previous 6 months, compared to only 4% of the noninvolved group. Youth involved in prostitution were more than five times as likely to report homosexual or bisexual identities. The age of first sex of these two groups also deserves comment. In this sample, 76% of the involved youth had had sexual intercourse before

age 15 years, and 26% had had sex before their 10th birthday. It is therefore not surprising that sexual abuse was 3.4 times as likely to be disclosed on the first visit by involved youth. In addition, physical abuse was twice as likely and satanic abuse more than three times as likely to be disclosed by involved youth.



Table 3. Psychosocial Interview Information on Youths Involved (n = 153) and Not Involved (n = 467) in Prostitution Psychosocial information Home Relatives Friends Shelter Streets Other/unkn$wn Education College Trade/vocational High school Junior high Drop-out Other/unknown Activity sports


Job Hang out Hobbies Other/unknown Drugs Intravenous use Hallucinogens Stimulants Inhalants Narcotics Marijuana Alcohol Cigarettes Drug problem No drug use Suicidality and Depression Depressed Suicide attempt Suicidal Mental health Sexual Behavior


Not involved



G.0 11.1 61.4 24.8 2.6

3.0 6.6 77.9 11.1 1.3

2.0 3.4 34.2 4.7 53.0 2.7

2.4 2.4 48.5 114 34.1 1.3

13.7 12.4 52.3 29.4 22.1

26.9 9.5 50.3 29.0 19.8

21.7 39.2 57.9 17.1 25.0 70.4 78.3 70.4 12.5 3.3

3.7 15.0 27.6 8.5 7.6 47.8 59.6 58.0 7.0 22.4

54.6 47.4 7.2 5.9

50.: 26.7 4.5 2.6

68.6 7 12.4 0.0

92.2 2.9 2.5 2.5

0.0 24.8 49.0 22.2 0.006 3.3

12.7 7.8 54.1 24.9 0.5 5.9


Heterosexual Homosexual Bisexual Undecided AGE AT FIRSTSEX

Never o-9 lo-14 15-18 19+ Unknown PROBLEMS WITH SEX

Patient states yes Survival sex Sexual abuse Physical abuse Satanic abuse


3.3 100.0 55.6 24.2 11.1

1.5 0.0 16.5 12.9 3.2



Discussion Witi runaway and homeless youth comprising the


serve this population. Staff at runaway sheliters and drop-in centers must receive training about these problems if they are to be effective with their clients. Finally, the various medical problems of youth involved in prostitution, especially the high levels of pelvic inflammatory disease and pregnancy, demonstrate the need for early medical intervention. Many of these young people are reluctant to approach traditional medical institutions; hence medical services must go to them. Clinics in youth centers, mobile screening units, and other nontraditional approaches to providing medical intervention will be necessary if preventive medical services are to be effective. As is often the case, these data raise more questions than they answer. Why are the youths in this study so much more likely to be farther from home than those in earlier studies? Why are more Caucasian youths involved? Are the substance abuse and mental health problems precursors to involvement or a result of involvement? Why are some homeless youths with similar multiple-problem profiles not involved in prostitution? To address these and other issues, more focused, small-sample, indepth interview studies with this population are needed.

majority of youth involved in prostitution, service providers must be able to identify those youths who are most at ,risk of becoming involved and make every effort to divert these young people from such child exploitation. Once these youths become involved in prostitution, their increasing participation in health-compromising behaviors (multiple sex partners and high levels of substance abuse) results in increased morbidity, as these data show. The high level of multiple drug use, including intravenous drug use, and the greater likelihood of gay or bisexual male involvement, combined with a large number of different sex partners, place the young people involved in prostitution at high risk for contracting and transmitting HIV. Innovative and creative informational and skills-building outreach programs must be developed and targeted at this population as a priority for reducing the spread of this disease. The high percentage of youths involved in prostitution who report a previous history of sexual abuse corroborates the findings of other studies (2,3). (Also see the article by Schram and Giovengo, this issue.) We must note that juvenile prostitution is technically a form of child sexual abuse and that these youth, who have already been abused, are continuing to be sexually abused on the skeets. PubReferences lic social service departments that have traditionally 1. Cohen M. Identifying and combating juvenile prostitution. “looked the other way” should priori&e these Washington DC: National Association of Counties Research, youths for intervention by the child protective ser1987. vice system. The additional fact that more of the 2. Silbert M, Pines A. Entrance into prostitution. Youth and Society 1982;13:471-500. youths involved in prostitution report experiencing 3. James J, Meyerding J. Early sexual experience and prostitution. both physical abuse and satanic abuse than noninAm J Psychiatry 1977;134:1381-5. valved youth reinforces the need for the active in4. Schick F. Service needs of maIe prostitutes. In: Tricks n’ Trade. volvement of the child welfare system. Chicago: University of Chicago Press, 1981:133-50. The multiple problems experienced by the youth 5. Janus MD, Scanlon B, Price V. Youth prostitution. In: Burgess involved in prostitution (drug abuse, effects of child A, ed., Child pornography and sex rings. Lexington, MA: Lexington Books, 1984:127-46. abuse, mental health and medical problems) clearly 6. Boyer D, James J. Easy money: Adolescent involvement in point to the need for a multidisciplinary approach prostitution. In: Davidson S, ed., Justice for Young Women. in providing appropriate and effective treatment. Tucson: National Female Advocacy Project, 1982373-97. Specialized knowledge about each problem area 7. Fisher B. A report on adolescent male prostitution.San Franmust be available among the professicnai$ -Wh& :, csc(3:. T.ir’n,:l::TtiJExai Sy:rStcsrA+%ciates, 1982.

A risk profile comparison of homeless youth involved in prostitution and homeless youth not involved.

All initial visits (n = 620) of runaway/homeless youths to an outpatient medical clinic over a 12-month period (July 1988-June 1989) were analyzed. Of...
462KB Sizes 0 Downloads 0 Views