Forty percent of homeless youth in this study reported condom use during their last episode of sexual intercourse, compared with rates ranging from 55% (among 12th
graders) to 64% (among 9th
graders) in a national school-based sample [30
]. One explanation for the relatively low rate of protected sex among homeless youth is that the disinhibiting effects of substance use impair their inclination or ability to use condoms. This explanation might seem reasonable given that two-thirds of homeless youth are current drinkers or drug users [12
]. However, demonstrating an event-level association between youth substance use and condom use has been surprisingly elusive in the literature, although few existing studies have focused on high-risk youth.
Similar to the results of Bailey and colleagues [20
], substance use prior to sex was common in our sample, with one-third of events involving alcohol or drug use. Most of the drug use events involved methamphetamine which, along with alcohol, has received considerable attention for its disinhibiting effect on sexual behavior [31
]. A key finding from this study is that condom use was less likely when hard drug use and, to a lesser extent, heavier drinking occurred prior to sex. In the case of hard drug use, a small number of prior event-based studies have reported a similar association [32
], but they have tended to include far fewer controls than the present study. Results from this study provide some of the strongest evidence to date that hard drug use increases the risk of unprotected sex, at least in certain populations. It is interesting to note that the majority of youth who reported on an event involving hard drug use did not perceive any connection between this behavior and whether a condom was used at the event, suggesting a need to target both the risk behavior (i.e., reducing hard drug use) and attitudes about the risk behavior (i.e., emphasizing its association with unprotected sex) in outreach efforts to homeless youth. In terms of alcohol use, the event-based literature has been mixed and several studies have not found the expected association with unprotected sex among youth in general [34
] or homeless youth in particular [20
]. We found some evidence that heavier drinking prior to sex increases the likelihood of unprotected sex, but with two caveats: the association was marginally significant and it only emerged in the full multivariate model.
Our analyses controlled for individual, relationship, and contextual factors in evaluating the association between substance use and condom use. However, we were also interested in examining whether these other factors might predict condom use in their own right. In terms of attitudinal factors, youth were more likely to use a condom if they held more positive attitudes about condoms and were more concerned about pregnancy, similar to other studies of adolescents and young adults [19
]. The finding on pregnancy beliefs is particularly interesting given the high rate of pregnancy among homeless female youth [4
], qualitative data from this project indicating that pregnancy is sometimes viewed as a means of improving their lives (e.g., by becoming eligible for transitional housing, forming a closer bond with a partner, motivating them to make positive changes [28
], and results from a national sample of runaway and homeless girls showing that pregnancy is related to a longer absence from family and feelings of abandonment [37
]. These studies suggest that some homeless youth may seek out parenthood because they view it as a panacea for the many challenges that they face, including feelings of disenfranchisement from their family of origin. Efforts to encourage condom use among homeless youth may need to address attitudes about pregnancy and parenthood, in addition to discussing the risk of HIV/STI associated with unprotected sex. In addition, the association we found between condom attitudes and protected sex indicates that helping youth find ways to use condoms without ruining the mood may encourage engagement in protected sex by increasing youth’s positive attitudes towards condoms.
In terms of relationship characteristics, we found that condom use was significantly less likely if the most recent sex partner was a boyfriend/girlfriend and marginally less likely if the relationship was perceived to be monogamous. Similar results have been reported in other studies of unprotected sex among adolescents and young adults [19
] and thus is not unique to homeless youth. While this is encouraging in that it suggests that these youth are basing their decisions about condom use at least partly on the perceived “riskiness” of their partner, it is also the case that some youth misjudge their partners and underestimate their risk of HIV/STIs. For example, slightly more than half of youth believed that they were in a monogamous relationship, but research on sexual concurrency indicates that individuals are often unaware when their partner has other partnerships [39
]. It is likely that at least some of the youth who reported that their most recent partner was steady or exclusive should have been using a condom with this partner. We also found high rates of relationship abuse among homeless youth, and that being in such a relationship was marginally associated with a decreased likelihood of condom use. The inverse relationship between abuse and condom use is similar to what we have found in studies of homeless women [24
], and likely reflects the fact that individuals in abusive relationships are more fearful than those in non-abusive relationships that their partner will respond violently if asked to use a condom [41
]. These results suggest that homeless youth may benefit from better understanding how they can protect themselves in different types of relationships – for example, ways to protect themselves (both physically and sexually) when a partner is prone to abuse, making sure that both partners get regularly tested for STIs if they decide to not use condoms, and how to re-introduce condoms into a relationship with a steady partner if the situation warrants it.
Finally, one of the most unique aspects of this study is our examination of contextual factors that might be useful in understanding condom use among homeless youth. Consistent with the existing literature [42
], communication about condoms was an important predictor of actually using them. Perhaps more surprising is that one in four couples talked about “pulling out” prior to having sex, and couples who had this conversation were significantly less likely to use a condom. Although this indicates some attention to pregnancy prevention on the part of homeless youth, the withdrawal method is not a reliable strategy for avoiding pregnancy (or STI transmission). Given that conversations about the use of this ineffective method appear to be relatively commonplace among homeless youth, sexual health promotion programs for this population may need to include a stronger focus on the withdrawal method in order to educate youth about its limitations.
Two other contextual factors emerged as predictors of condom use: whether the event involved a chance meeting and having sex in a non-private place. We expected that chance meetings would be associated with unprotected sex because of the unanticipated nature of the sexual event; indeed, other research has found that adolescents are more likely to use condoms when the sexual encounter was expected [35
]. However, we found the opposite and further research is needed to understand this finding given that it remained after controlling for the various demographic, attitudinal, relationship, and contextual factors. Nearly one in three youth reported that their most recent sexual event occurred in a setting where they lacked privacy, and having sex in a non-private place decreased the likelihood of using a condom. The high rate of non-private sex is not surprising given that youth typically stay in settings that afford little privacy such as abandoned buildings/squats, outdoors, or a motel room rented with others [10
]. We did not collect more detailed data to understand the ways in which the living environments of homeless youth, including the lack of privacy, impact their condom use and other aspects of sexual behavior. This seems to us a critically important direction for future research. Nonetheless, results from this study suggest that lack of privacy is a risk factor for unprotected sex that is unique to this population and important to address in programs aimed at encouraging condom use. This finding additionally reinforces the need to help youth create more stable living situations. Depending on the age and needs of the youth, avenues for enhancing living situations may include re-unification with family or guardians or permanent housing with supportive services as necessary.
An important strength of this study is the large probability-based sample of homeless youth recruited from shelters, drop-in centers, and street venues. The rigorous sampling design used for this study bolsters our confidence in the generalizability of these results to the population of homeless youth in the Los Angeles area (although not necessarily to other geographic areas). Examining the association of substance use with unprotected sex within the context of other individual, relationship, and contextual factors is an additional strength of this study. However, the study also has some notable limitations. Measurement limitations include the low reliability of the condom attitudes scale, as well as reliance on retrospective self-report for information on the events. In the latter case, however, we attempted to minimize social desirability biases by assuring youth that their responses would be held confidentially, and to minimize memory biases by focusing on the most recent sexual event. Our confidence in the accuracy of these reports is bolstered by the fact that the majority of most recent events occurred within one month of the interview and were remembered “very well.” In terms of the associations between substance use and unprotected sex, it is a limitation that we cannot completely rule out that these are due to unmeasured third variables (e.g., propensity towards risk-taking), despite the wide range of individual, relationship and contextual factors that we examined. Finally, sampling multiple sexual events through a diary approach [19
], although perhaps prohibitively challenging in studies of homeless youth, would have allowed us to investigate the co-occurrence of substance use and condom use over an extended period of time.
Efforts to reduce substance use among homeless youth, and educate them on the potential impact of their use on the ability to practice safe sex, may lower the risk of HIV/STIs and pregnancy by increasing the use of condoms. In addition, our results suggest that programs to encourage condom use should include a focus on helping youth form more positive attitudes about condoms, correcting erroneous beliefs about pregnancy and the withdrawal method, helping youth develop skills to negotiate condom use in different situations, and addressing the barriers to using condoms in the context of a living environment which affords little privacy. In the long-term, helping homeless youth to create more stable living situations may itself be an effective strategy for reducing HIV/STIs and teen pregnancy in this vulnerable population.