These detailed descriptions of 56 sexual events are illuminating in that they highlight the considerable diversity and complexity in the sexual relationships of homeless women and provide additional insight into the growing literature on the factors that influence safer sex practices among impoverished women. We summarize our results below.
First, we found that homeless women had a far broader range of sexual relationships than perhaps is commonly presumed. They reported trading sex for money and drugs with “Johns;” having sex with acquaintances, friends, boyfriends, and ex-lovers; and maintaining long-term, stable relationships with husbands and common-law partners. Interestingly, in none of the events did women describe having sex with strangers.
Second, we were struck by how often this sample of homeless women described their emotional attachment toward some of their sexual partners. Not only did they describe strong emotional bonds with their long-term partners, but they were clearly emotionally attached to many of the friends and ex-lovers with whom they had sex. It may be the case that some of these women are seeking to fulfill a need for emotional attachment when they have sex with some of their more casual partners. Seeking emotional attachment may come at a price for these women if it discourages them from using condoms with partners who they do not know well or with whom they do not have an exclusive relationship.
Third, our results highlight the fact that all encounters are not equal. Although we only looked at encounters where sex occurred, the reasons for meeting up in the first place varied dramatically. Sexual encounters where the primary purpose of the encounter was to acquire drugs or resources such as money, food, or shelter were quite different from encounters where the primary purpose was for emotional intimacy or for physical and sexual desires. These differences in turn affect the factors that homeless women consider in choosing to have sex or use a condom, including the role that alcohol and drugs may play in such decisions. Decisions about who to meet and for what purposes put women at different kinds of risk. For example, women who meet primarily for drugs or for resources are in a particularly vulnerable position.
Fourth, our 56 interviews suggest that homeless women are relying on a wider array of types of people to fill their needs for not only resources (and sometimes drugs), but also for emotional intimacy and physical desires. What seems to put homeless women at most risk is that many of them appear to profess a level of trust toward their casual partners that is typically reserved for long-term and emotionally close partners (e.g., boyfriends, husbands, and common-law partners). That is, women in our sample appear to grant some ex-husbands and ex-lovers, friends, acquaintances, and even some “Johns-they-regularly-date” with similar kinds of trust and safety that they would afford an established boyfriend or husband. In contrast to husbands and boyfriends, women may have little knowledge of or influence over the sexual activities of ex-husbands, ex-lovers, friends, and acquaintances. Possibly, it is these trusted casual partners who represent the most risk to the women.
Fifth, our results suggest that relationship commitment and involvement set the context for other factors that may influence condom use. Therefore, it may be worthwhile to look at condom use decision-making separately with serious and casual partners. Consistent with other research, we found that women at risk for HIV infection are less likely to practice safer sex if they report higher levels of relationship commitment (Castañeda, 2000
) and involvement (Morrill et al., 1996
) and were less likely to use condoms with longer term or steady partners compared with casual partners (Marin et al., 1998
; St. Lawrence et al., 1998
; Tortu et al., 2000
; Wingood & DiClemente, 1998
). Our results are also in line with findings from recent studies by Tucker et al. (2007)
and Harvey et al. (2006)
that found relationship commitment predicted more frequent engagement in unprotected sex with a partner, even after controlling for the type of relationship (primary vs. casual). Our results suggest that in terms of safe sex, factors like drugs and alcohol as well as women’s perceptions of trust and safety play out within the complex context of social relationships.
One of our most striking findings is that condom use was more likely when drug use occurred prior to sex with casual partners, but less likely when drug use occurred prior to sex with serious partners. A non-significant trend in the same direction was found for alcohol use prior to sex with casual versus serious partners. Although little attention has focused on the possibility that substance use might be associated with less risky sex under certain conditions, this result is consistent with a recent diary study by Leigh et al. (2008)
showing that drinking was associated with increased condom use with casual partners among women. Alcohol myopia theory (Steele and Josephs, 1990
; MacDonald et al., 2000
; George et al., 2007; Davis et al., 2007
) may provide one explanation of our findings. This theory proposes that alcohol intoxication (and we suggest possibly drug use) restricts attention capacity so that people are highly influenced by the most salient cues in their environment. For sex with casual partners, this may be related to sexual risk. Alternatively, these findings could be due to differences in how much alcohol and drugs were used with casual and serious partners. We fully recognize that such explanations are speculative. Unfortunately, our limited sample size makes it difficult to untangle the interaction between partner type, substance use, and condom use and the probable confounding with sexual motivation and risk perception. For example, some women described situations in which they had sex to obtain drugs or money that they might not otherwise have had. In these situations, their casual partners may be known to be particularly risky and the women may be more determined to use condoms. Perhaps they anticipated and planned for the events and brought condoms. The decision to use a condom may be made, and the sex may be over, before the intoxication occurs. In such circumstances, it may be impossible with these data to disentangle a complex and confounded interplay of partner choice, sexual motivation, trust, safety, substance effects, and condom use decision timing.
Our data also suggest that how much a woman trusts or feels safe with her partner is a driving force in predicting condom use and is particularly powerful when it comes to making choices with more casual partners. As mentioned above, we suspect that some homeless women have expanded the range of partners they trust or feel safe with to include casual partners such as ex-boyfriends and ex-spouses; that is, people whose sexual activities are less well known and over whom they have less control or influence. As Misovish et al. (1997) note, using or not using condoms symbolizes trust, emotional intimacy, and commitment within the relationship. Unlike many other studies that rely on surveys, the data from our detailed interviews allows us to better understand how such symbolic linkages play out in real-life decision-making processes – often in complex ways. For instance, we found events where women reported not using condoms because they felt emotionally close to their partners and trusted them to keep them safe, as well as events where women reported not asking their more serious partners to wear a condom because this would indicate that they were not committed to the relationship.
Our work also adds to the discussion over the role that gender-based power dynamics may play in safe sex practices. Some researchers suggest that relationship power is a key contextual variable that shapes women’s ability to engage their partners in HIV-related protective behaviors (Amaro & Raj, 2000
). Others suggest that power dynamics by themselves are not sufficient to explain risk among women and girls (Gutiérrez et al., 2000
). Our data suggest that the role of power dynamics varies from case to case. We find examples of women who explicitly (and sometimes quite adamantly) take control of decisions about condoms, and we find examples of women who (for a variety of reasons) appear to relinquish control of this process. Our results are consistent with others who have found that the majority of low-income women feel that they have at least some control over condom use with their partner (Cabral et al., 1998
; Soler et al., 2000
). It is interesting to note that in 3 of the 5 events where condoms were available but not used, women appeared not to bring up the issue of using a condom because they had concerns regarding how it might influence the relationship with their partner. Our findings also seem in line with those of Weeks et al. (1995)
who concluded that the scarcity of available men, combined with women’s reliance on these men for support, may tip the balance of power toward the male partner and erode impoverished women’s ability to engage in HIV self-protective behavior such as condom use. Because heterosexual intercourse accounts for 83 percent of women’s HIV/AIDS diagnoses (CDC, 2007
), continued attention to condom use as an HIV protective device is necessary.
Interventions that hope to assist women in practicing safer sex may want to address women’s understanding of “trust” and “safety” with a partner as well as tackle ways to interact with men whose sexual behaviors are beyond their knowledge and control. It is clear from our diverse set of sexual episodes that there is a need to increase women’s recognition of partner risk and their ability to negotiate safer sex in ways that do not threaten the relationship. Given the diversity of circumstances that homeless women experience, interventions should target women in committed relationships as well as women who have sex outside of committed relationships. Such interventions should attend, for example, to commitment and its influence on condom use. Programs that emphasize communication and negotiation skills, strategies to develop assertiveness, and effective conflict resolution may be effective (e.g., El-Bassel et al., 2005
; Theall et al., 2003
This study faces several limitations. Although both shelters and women were selected randomly, the sampling design was such that population prevalence estimates could not be generated for homeless women who use shelters in Los Angeles. To be fair, however, our intent was neither to generate precise and accurate population estimates nor to generate formal models to predict safe sex practices. Instead, the goals of this exploratory research were to: (1) capture the range of women’s sexual experiences (including women’s thoughts, feelings, behaviors, and the social and physical contexts in which sexual events are embedded); (2) identify – at a relatively crude level – what kinds of experiences were most and least prevalent; and (3) to generate hypotheses about mechanisms that are likely to lead to unsafe sexual practices, including the role of alcohol and drugs. The confidence in our findings comes from the degree to which the patterns appear across a diverse sample of women and sexual events rather than from a more statistically representative sample. We believe that the combination of a purposeful and diverse sampling strategy, a comprehensive conceptual framework to guide our interviews, and a semi-structured format that allowed women to describe their experiences in their own words was both an appropriate and cost-effective approach for obtaining our goals.
Second, the use of recall data to identify behavioral patterns poses a number of challenges. On the one hand, it is possible that hindsight and social desirability may have affected women"s responses and on the other, it is possible that women might have confused some of the details trying to remember past events. Our sense, however, is that women were very forthcoming with their stories. The fact that many women provided graphic sexual descriptions and explicit unprompted discussion of sex for resources and drugs makes clear that they had few problems talking about sensitive issues. We encouraged women to tell their own stories in their own words and, more often than not, prompted them for more details and a fuller understanding of their experience rather than asking them to give rationalizations for their behavior. Further, whenever interviewers saw inconsistencies, they asked women for clarification. This often resulted in not only a more in-depth understanding of the situation but also more insight into the kinds of rules and schemas that the women used.