The present study examined the association between five types of childhood maltreatment and sex work involvement among drug using street-involved youth. A high prevalence of abuse was found, with rates ranging from 32.4% to 93%. These rates are similar to a recent, methodologically comparable study of adult drug users (Medrano et al., 2002
). Further, two types of childhood maltreatment, sexual abuse and emotional abuse, were found to be independently associated with sex work after controlling for socio-demographic variables. Because we were not able to assess the additive burden of abuse due to collinearity of variables, we restricted the analysis to the relationship between each of the separate types of abuse and sex trade involvement.
In terms of the separate associations between sexual abuse and sex work, and emotional abuse and sex work, a number of points can be made. First, a possible explanation for the association between childhood sexual abuse and later sex work involvement may be that children who are sexually victimized develop psychologically and emotionally in ways that make them vulnerable to continuing sexual predation. Conversely, childhood sexual abuse may create a propensity in the victim toward risk taking behaviours (substance use, running away from home [Kingree, Braithwaite, & Woodring, 2001
; Tyler, Hoyt, & Whitbeck, 2000
]) that in turn lead to situations in which survival sex work is one of few remaining options.
The connection between childhood emotional abuse and later sex work involvement may involve similar factors. Emotional abuse has been defined as “acts of omission and commission committed by parent figures, which are judged to be psychologically damaging on the basis of a combination of community standards and professional expertise” (Doyle, 2001
, p. 388). A review by Spertus, Yehuda, Wong, Halligan, and Seremitis (2003) lists a number of emotional and psychological effects of emotional abuse, including depression, anxiety, suicidality, low self-esteem, personality disorders, poor body image, sexual dysfunction, and compromised physical health. These psychological effects may combine to create a vicious circle for many youth, wherein poor coping skills and resources are not adequate for the high-risk situations in which they find themselves, thereby increasing their dependence on strategies such as trading sex for survival. This in turn would compound risks for which they are poorly equipped, perpetuating a downward spiral from which it is difficult to break free without external intervention.
The finding that trauma associated with emotional abuse was independently associated with sex work among street-involved youth was unexpected. Although severe emotional abuse in childhood using the Childhood Trauma Questionnaire was recently found to interact with Black ethnicity in independently predicting involvement in sex work among an adult female drug-using population (Medrano et al., 2003
), this is the first study of its kind to show an independent relationship between childhood emotional abuse and youth involvement in sex work. The finding has important implications for intervention programs that address high risk behaviors such as sex work among youth. Not only do interventions need to address childhood sexual abuse as a risk factor—for which there has been evidence for some time—but attention also needs to be paid to experiences of emotional abuse as a potential determinant of high risk behavior.
Challenges to service delivery models that address childhood emotional abuse need to be considered, however, as emotional abuse can be more difficult to assess than sexual or physical abuse or physical neglect. When situated within the context of sex work involving drug using populations, a number of implications emerge for working with vulnerable populations who have experienced childhood emotional abuse. Sex work takes place within a complex interaction of contextual, social, structural, and psychological factors that mediate negotiations regarding condom use, selection of partners, sexual and drug-related practices, and health seeking behaviors. Given that childhood emotional abuse has been previously associated with lifetime exposure to trauma and increased vulnerability in high-risk situations (Spertus et al., 2003), and in this study was found to predict engagement in sex work among street-youth, the current absence of prevention and harm reduction strategies that screen for emotional abuse among drug-using youth and adolescent initiates of sex work is of particular concern. Harm reduction strategies targeting street-involved youth need to consider the impacts of unaddressed emotional abuse on negotiation of sexual and drug-related risk behaviors and the potential impact of power dynamics on youths' ability to protect themselves. Interventions effective at reducing harms associated with early emotional abuse will need to be situated within the larger social, structural and environmental context of sex work among drug-using youth. The current prohibitive framework of sex work in the Canadian setting has been shown to displace sex workers to dark and deserted areas and further from social supports, thereby decreasing sex workers' ability to protect themselves and increasing vulnerability to violence and assault (Goodyear, Lowman, Fischer, & Green, 2005
). Previous studies have shown that enhanced social support and reduced social isolation are important protective mechanisms against past emotional abuse (Doyle, 2001
). Socio-legal policy reforms that reduce harms and the social isolation faced by sex workers and that facilitate sex workers' ability to negotiate their situation may be crucial in engaging this population and countering the adverse impacts of past emotional abuse. In addition, given the increased distrust among those with a history of emotional abuse (Doyle, 2001
; Medrano, et al., 2003
) coupled with high levels of stigma and criminalization of sex work, innovative strategies and policy reforms that actively engage drug using youth in the development and implementation of interventions will likely be effective in facilitating access to social support and building trust among emotionally-abused drug-using youth. Finally, childhood emotional abuse has been shown to result in low self-efficacy and self-care (Spertus, et al., 2003), suggesting that capacity-building and low threshold employment and skills training may help to mediate the adverse impacts of past emotional abuse among this population of street youth. Ultimately, of course, the goal of such interventions would be to help youth transition out of the high-risk environments of the street and the sex trade completely. It is recognized, however, that a multi-systemic approach is required to meet this objective, which goes beyond front-line interventions and addresses the root causes of dysfunction in families and society at large.
Lastly, high linear correlations between the five types of abuse were statistically confirmed for this population, and the specific correlations say something about how different types of abuse combine. Of specific interest is that, when examining the correlations with emotional abuse, sexual abuse was in fact more weakly correlated in comparison to physical abuse, emotional neglect, and physical neglect. This offsets somewhat our concerns that the prevalence of trauma associated with emotional abuse may have been inflated due to confounding with sexual abuse.
The present study is limited first by the fact that despite extensive street-based outreach efforts and snowball sampling methods, the sample is not representative. Of note, despite recruitment efforts, females and younger youth (ages 14 to 18) may be under-represented, and the study may not fully reflect issues specific to these groups. Having said that, the demographics of the ARYS cohort are consistent with other studies of street-involved youth conducted in the same locale (Ochnio, Patrick, Ho, Talling, & Dobson, 2001
). Nevertheless, the findings should be interpreted with caution and limits to generalizing to other street-involved youth populations recognized.
Next, it is acknowledged that samples involving marginalized populations are vulnerable to socially desirable responding (Des Jarlais, Paone, & Milliken, 1999
). This bias may be compounded in this sample among participants under age 19 who were warned in the consent process about the researcher's duty to report abuse to authorities. However, with regard to self-reporting of abuse, there is previous evidence indicating that false-negative reports of abuse are more common than false-positive reports (Bernstein & Fink, 1998
). Other behaviors explored in the study may be underestimated, such as injection drug use and sex work involvement, despite reassurances of confidentiality and interviewer efforts to build trust and rapport with participants. Therefore, due to a possible bias toward under-reporting in the sample, findings should be considered as likely conservative estimates.
It is also possible that the prevalence of trauma associated with emotional abuse has been inflated due to confounding with sexual abuse. Due to the high correlations found between variables in the study we were unable to examine the independent effect of the various forms of abuse. As such future research should explore the potential association between childhood emotional abuse and sex work involvement, in the absence of childhood sexual abuse.
In summary, the study extends the literature on associations with childhood maltreatment among vulnerable populations in a number of ways. First, it parses different types of childhood maltreatment experienced by those who engage in sex work, and the level of trauma associated with each. It also focuses on those who may be especially vulnerable to the type of tragic consequences described at the beginning of this paper—young people who use drugs and engage in sex work. We found that separating types of childhood maltreatment into physical, sexual and emotional abuse, and physical and emotional neglect yields a more precise contextual description of associations with sex work among street-involved youth than previous studies. The finding that not only childhood sexual abuse, but also childhood emotional abuse independently associated with sex work has important implications for intervention efforts with high risk youth. In order for early intervention efforts to be successful with youth, they must have an evidence-based foundation and be relevant to youth's life experiences. As we are currently witnessing in the Downtown Eastside Vancouver, the cost of neglecting early intervention efforts is too high in too many sectors—public health, the justice system, civil society, and personal lives.