3.1. Participant Characteristics
Participants ranged in age from 18–26 years and most lived in an emergency shelter or transitional living program (TLP). Participants older than 24 were generally former shelter clients returning for case management and drop-in services. Most of these clients lived in adult emergency shelters or long-term adult supportive housing like the single-room occupancy accommodations provided by the HIV/AIDS Services Administration or Department of Homeless Services. In terms of gender, 61% of participants were male, 21% male-to-female transgender, 16% female, and 3% female-to-male transgender. Racially, 12% were white, 52% Black, 30% Latino, 3% Native American, and the rest of other or mixed race. All were attracted to, and/or primarily had sex with, people of their own biological sex, including the “trans-amorous” males who preferred male-to-female transgender partners. The vast majority of participants had been tested for HIV recently enough to be relatively confident of their status. Only two had never been tested. HIV-positive or HCV-positive status was reported by 16% of participants. At least one occasion of sex work was reported by 37%. Involvement in sex work did not seem to be specific to any race, gender, or sexual identity.
In the presentation of results below, figures for age have a random number between −1 and 1 added to them in order to preserve anonymity. Also to preserve anonymity, we labeled every response from someone positive for HIV or Hepatitis C with “Pos” and deliberately did not clarify which infection the participant had.
3.2. “Wrap It Up” (Always Use Condoms)
Condom-related socialization in LGBT youth services favors simply using a condom every time and maintaining rigid boundaries against unsafe sex. Statements in 31 interviews reflected this mentality, named by seven interviewees as “wrap it up” or “strap up.” Components of this mentality included the following.
- Insistence on condoms, even if it meant not having sex:
If you don't want to use condoms, we not um gonna do nothin' (Latino gay male, 23).
(ii) Using condoms even if aroused, high, drunk, tired, or averse/allergic to latex:
She says um, baby, where's my covers at? I'm so drunk that I'm like my eyes is so closed so I'm like, “why would it…why in the hell would I know where your covers is at?”…we wound up having sex that night…With a condom. (Black trans-amorous male, 23).
(iii) Associating condoms with social responsibility and conventionality (in the following quote, note “coward” as a moral judgment upon someone who would put a partner at risk):
He was like, I love you, and as soon as he said that, I just I got off him, and I made him put a condom on. Because I don't want to be a coward…I couldn't be that cruel (Latino gay male, 25, Pos).
(iv) Repudiation of specific beliefs common among peers, particularly the idea that unsafe sex is okay with a partner that has proven HIV-status or that one “trusts” on other levels:
She can show me all her papers and be clean and I'll still use it (Latino bisexual female, 19)
The best looking person can have it (Black bisexual male, 20, Pos).
I don't care like how long we've been together we can be together for week two weeks two years and the whole using condom thing will never change (White trans-woman, 21).
Maybe you trust them and they don't even know that they have something (White/Latino gay male, 18).
Also emergent under this theme was a quantitative finding: of the nine HIV-positive participants who mentioned how they had become infected, all believed they had acquired it from primary partners.
3.3. Trust in a Long-Term Partner Not to Cheat or Be HIV-Positive
Although the most conventional policy was “wrap it up,” the most common policy, cited in 49 interviews, was one of calculated risks based on trust in long-term partners not to put them at risk for an STI. HIV-positive and HCV-positive participants also engaged in calculated risk of superinfection or additional STIs. This policy often included benchmarks for how long they would have to be together to forego condoms, for example, two years (Black gay male, 20), or 2-3 months (Black lesbian, 20). Some also observed a policy of getting tested together, mentioned in 17 interviews:
If …we both had been tested and then really believed that they were safe and if we'd been together for two years or married or something…maybe (Black trans-man, 24).
HIV- or HCV-positive participants could avoid superinfection from unprotected sex with primary partners through serosorting and trusting partners to be faithful. This was reported in 2 interviews:
We have sex without (condoms). I know we shouldn't, but I know his status and I know my status, I know I caught mine from him, so we have sex every night without a condom (Latino gay male, 22, Pos).
In 3 cases, associating non-use of condoms with trust led to an inference that a long-term partner who suddenly insisted on condoms was cheating:
We had a fight actually, our first fight after a whole year. He accused me of sleeping with somebody else because I wanted him to use a condom…He was like y'all trust me you don't trust me…just has his ways of making you feel so bad for him and then I'm like you know what just to prove I trust you I won't use a condom. That's where I fucked up (Black gay male, 24).
3.4. Love and Emotional Intimacy with Long-Term Partners
In 17 interviews, unprotected sex with long-term partners was motivated by, or an indicator of, emotional intimacy. These emotion-based choices are distinct from the rational, calculated risk of those made under the “trust” norm:
When I loved him, I trust him. I had, I mean, I felt like, he was like the same way I was, and I wasn't messing around, I wasn't lying, I know that (Black trans-woman, 25).
3.5. “The Moment” and Sexual Pleasure
Willingness to compromise safety for pleasure was mentioned in 9 interviews. Such choices included not insisting on condoms, not disclosing HIV-positive status, not taking “using a condom during oral sex seriously” (Black gay male, 23), or dropping the condom requirement in a relationship after days instead of the months it would take to be sure of a partner's HIV status. In contrast to the trust norm and affect heuristic, these participants actually factor considerations like discomfort using condoms into cost-benefit analyses around HIV risk:
Condoms irritate me for some reason I…it might be a mind thing, but in my mind, I think they irritate me, they hurt, I don't like the way they feel, they're uncomfortable…And, um, he didn't really like to use them anyways, he liked to have raw sex like I did so it was…a two-way thing. We just stopped using them at the end (Latino gay male, 23, Pos).
Beliefs and experiences in which the moment was clearly more important than safety were mentioned in 13 interviews. Their motivation could be sexual desire, emotional vulnerability, or both:
Because sometimes, I mean, there's been sex, there's been sex everywhere. In clubs, in cars, in the streets, in the alleys and parks in trains and bathrooms. You name it, I've done it…heat of the moment, and you're drunk or you're high, you're not thinking about consequences, you're just thinking about getting it. Some people have brought it up, or I've brought it up, and I have just like, “don't worry I'm safe.” And that's like one of the sexiest things you can say; that kind of ruins the whole thing if you say “I don't have HIV” or “I don't have no STDs,” it's just stop, just a minute, it's just sexier to say “I'm safe, don't worry, I'm safe” (Black gay male, 22).
3.6. “Go with the Flow” to Avoid Awkwardness of Condom Negotiation
Yet another policy, evident in 10 interviews, was to avoid the awkwardness of condom negotiation and simply “go with the flow.” It is distinct from the above in that the mindset in these encounters is not participants' own satisfaction but desire to please, or avoid problems with, either romantic or sex work partners:
I knew if I had said something about it, it would set up a drama (Black trans-woman, 23, Pos).
It all depends on my customer…if he asks me first, then I say okay. If he don't ask me, then I'm not going to use it…(Interviewer: So you pretty much go with…) the flow (White trans-woman, 20).
3.7. Risk Context: Open Relationships
Engagement in relationships without the expectation of exclusivity was reported in 23 interviews. (Some participants initially interpreted “open relationship” to mean one that was not secret or closeted; this was clarified for them.) When asked about harm reduction rules, 12 reported using condoms with both their primary partner and other partners:
With me, it was mandatory to use condoms every time. It was an open relationship, I knew at the end of the day that the other person was going to have sex with somebody else…For you to touch me, you know, and feel that you didn't have to be protected, I just, to me, that doesn't sit right with me, I don't feel right. I feel like the best thing is to protect yourself (Black lesbian, 20).
Eight reported using condoms with other partners, but no condoms with their primary partner:
And, when I was with him, I was with him, when he was with me he was with me, but when we're separated, we're single, and we can do whatever the fuck we wanted, as long as we used a condom and we didn't bring something back (Latino gay male, 24, Pos).
Three described situations when the nature of the relationship changed, so did the rules about condoms:
He was like, “you can have sex with this person, I can have sex with that person, is that all right with you? Can we do it like that?” I was like, “sure,” ‘cause I really didn't care about him like that…then…I wouldn't do it with him ‘cause I'm in love with him, he was like, “fine, we won't do it” (Native American gay male, 21, Pos).
Those agreements actually didn't last because my partner didn't meet with them…He didn't want to use condoms (Black gay male, 20).
3.8. Risk Context: Sex Work
Homeless LGBT youth often encounter opportunities to trade sex for money or housing, even though only a minority (at least, within this shelter-homeless population) actually participate. Their overall norms for condom use—that is, that protection should be involved in encounters with partners they do not love, trust, desire, or plan to be with long term—generalize to protect them in sex work situations. Twenty-five interviews of youth who had engaged in sex work affirmed adherence to this norm:
I hate it when like the client's like “I don't have anything, I don't have anything.” I'm like, “I'm not going to take that chance, I'm sorry. I don't know you that well, I just met you right now, and you think I'm going to believe you?” (Black lesbian, 18).
Seven interviews of youth who had engaged in sex work reflected willingness to not to use condoms in a sex work context:
I needed more money, therefore, I asked him “I can take this condom off if you give me a extra…extra.” And they usually say “Well, how much,” and they throw me a $20. If they throw me anything less than a $20, I say “no, I can't do it” (Black trans-woman, 21).
Even for youth who do not engage in sex work, the presence and availability of sex work is still part of their environment. Seven interviews of participants who had never engaged in sex work reported receiving and declining offers:
I helped bring her bags in her car, I was 17 years old she was about 29 or 30 she said she'd pay me $500 to lick my ass. And that was shocking to me. She had the money too. And I'm not going to lie, I wanted the money bad but I couldn't bring myself to do it. I've had so many offers. So many offers (Black gay male, 21).
An additional three mentioned no actual sex work or offers for it, but did have “gray area” experiences between casual sex and sex work:
Gets $200 from the ATM, hands me $180…catching a cab back…I'm finger poppin' her and shit, we having sex…when we got to the place, she hops out of the cab and runs straight across the street …yelling, “ Oh, all you want me for is sex!”… I don't even know you from a hole in the wall, but we still fucked. And she just runs…the guy at the front desk was like, “Oh, she always does this” (Black trans-amorous male, 22).
I fucked him with a condom and I woke up and there was like $300 right beside me. So I don't know if I was paid I was a paid ho; I probably was. I'm trying not to think of it like that (Black bisexual female, 24).
An additional seven interviews that received none of the previous four codes still reported peer encouragement toward sex work:
A lot of people of offered me like, you should put up an ad on Craig's List…there are many a time, because a lot of my friends, a lot of them, do sex work. And many a time, the money that they bring in, sometimes that thought is like a pounding thought in my head (Black trans-amorous male, 20).
3.9. Risk Context: Negative Emotional States
Psychological stressors such as low self-esteem, depression, grief, and a general loss of meaning and purpose were described as wearing down condom boundaries in 23 interviews. These situations are distinct from the cost-benefit analyses mentioned above. Rather, psychological stress diminished these youths' capacity to enforce boundaries:
I was in love. And, it was kind of like my heart was broken, depression fell in, and I just didn't give fuck, if it happened… I remember a point in time where …I actually wanted to get HIV…I figured if I get it, I'd die. If I died, then, no one could say it was suicide…I was trying to destruct myself without having to be the weapon (Latino gay male, 24, Pos).
Only one interview affirmed, while 55 repudiated, that housing status had any direct effect on condom use. Any effect of homelessness on condom use was perceived to be indirect, through negative emotional states:
I think that plays a part in me not caring when I engaged in sex, because I didn't care about myself. I'm just now getting to a place where I'm starting to care more about me. You know, ‘cause, back then, I didn't care, you know, I was still dealing with a lot of hurt and a lot of pain from my past, and growing up and the different experiences with being gay and everything like that. That, it made my self-worth seem like it was, I had none. So, I think that when a person is homeless, you're still dealing with depression, which comes from being homeless, or it could come from the experiences in their lives (Black gay male, 25).
This effect of negative emotional states could intersect with the norm of unprotected sex with primary loved partners in order to create a particular risk context:
When you're homeless and you have nobody you just want to feel like you've got somebody and you, when it comes to sex, you, I think that not using a condom expresses that you want, um, you want more from the person or you want them to realize that anything between you is greater than using a condom (Black gay male, 21, Pos).
3.10. Risk Context: Drugs and Alcohol
Although current drugs of choice in this sample were primarily marijuana and alcohol, hard drugs were still a part of their risk context. In 14 interviews, participants reported that they never use drugs or alcohol. An additional 12 reported that they do not use drugs or alcohol to the point of intoxication. Another 12 reported, with various degrees of intentionality, not having sex while high or drunk:
I've never really tried to have sex under the influence, never really wanted to do that. I have gotten drunk after sex of course, because of the depression that I feel from it (Bisexual black male, 22).
And 11 reported that, although they would have sex while high or drunk, it either had no effect on their condom use or, because they were fully aware of the dangers, made them more careful:
Oh hell, no…I always make sure that I have a condom…doesn't matter how drunk I am…doesn't matter how drunk he is. It's always a condom (Latino gay male, 20).
Alcohol, it impairs your judgment, so you always have to be on point. Alcohol, it will fuck you up. (Interviewer: Marijuana?) Please. That shit don't do nothin' (Black lesbian, 21).
Some experience with hard drugs was reflected in 16 interviews. Only two reported using sex work or survival sex to support a habit:
Yes, I have had sex before for money… to keep my (cocaine) habit going…I was like 14, 15, and I would go and sell my body and then go back home. And my parents thought I had a job (Bisexual black male, 22).
3.11. Transformative Confrontation with HIV and HCV
HIV “scare” experiences (few participants were more than distantly aware of HCV) were reported in 18 interviews. These included seeing the effects of HIV and HCV on others, catching other STIs themselves, or realizing, after an unprotected encounter, that they had put themselves at risk. This usually made them revise their condom policies:
That syphilis shot is no joke that's some big ass needles …after this whole syphilis incidence, I was not playing. So I don't care how long you're with me, you're going to use a condom or whatever until I feel comfortable. Actually, you might have to use a condom forever, because I'm going to be mad paranoid now, I'm going to be like super paranoid, I'm going to cover myself in Saran wrap…I might catch something that you won't have a shot for (Black gay male, 24).
Among the 13 youth who were positive for HIV or HCV, nine reported that their infection was a turning point in their lives:
I just found out like three months ago…it felt like you're invincible and then all of a sudden you're infected and everything changes. Your demeanor, the way that you carry yourself, your whole life, it's….it's all different, and it doesn't seem like it's a positive thing, ‘cause truthfully it really isn't. But, it all depends how you deal with it… I've really done a lot of support groups ‘cause that was really what kind of supported me along the way to stay positive…having someone to talk to that's been through it before (Latino gay male, 19).