MICHAEL C. CLATTS AND W.

REES DAVIS

Youth at Risk Project National Development and Research Institutes, Inc. New York

A Demographic and Behavioral Profile of Homeless Youth in New York City: Implications for AIDS Outreach and Prevention
Rapid changes in the world market economy have served to destabilize many local institutions, widening the gap between the rich and the poor and undermining viability of key social and economic institutions such as family and household. Among those most deeply affected by this displacement are children and adolescents, many of whom are forced to leave family institutions before they have acquired the skills and maturity needed to become economically self-sufficient. Fending for themselves amid the vagaries of the underworld of virtually every major city in the world, these youths are at exceptional riskfor a wide range of poor health outcomes and premature death. While perhaps a familiar sight in many non-Western countries, this phenomenon also has emerged in the industrialized world, a fact that accounts for the rise in exposure to violence and disease among street-involved youth and young adults in nations such as the United States. There are as yet few empirical data available about the nature of these youth populations or the constellation of behaviors that place them at increased risk for disease outcomes. In this report we construct a demographic and behavioral profile of the homeless youth population in New York City, particularly as behavioral patterns relate to risk associated with HIV infection, [homeless youth, AIDS, street economy]

omelessness in the United States has increased dramatically over the last two decades (Burt 1993; Link et al. 1994; Rossi 1989; Susser et al. 1994), following massive redistribution of wealth in the American economy (Mishel and Frankel 1991; Wilson 1996). Homelessness is a serious public health problem and is generally associated with chronic diseases such as enteric parasites,

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bronchial infections, asthma, pneumonia, conjunctivitis, and malnutrition. Homelessness also presents a serious challenge to the control of a number of infectious diseases such as tuberculosis, sexually transmitted diseases (STDs), hepatitis, and HIV infection (Brickner and Scallan 1986; Gelberg and Linn 1989; Hibbs et al. 1994; Struening and Padgett 1990). Once composed largely of adult males, today's homeless population is more complex and includes larger and growing proportions of women, ethnic minorities, and young people. Although reliable figures about the size and distribution of the homeless youth population have not been established, it is estimated that perhaps as many as 2 million in the United States are homeless and that 200,000 live as permanent residents of the streets (Robertson 1991). In New York City, the homeless youth population is estimated to number as many as 20,000 (Schaffer and Caton 1984). Some are transitionally homeless, leaving home or foster care for relatively brief periods of time. A substantial and apparently growing number remain homelessliving from day to day in a precarious and often violent world on the streets, doing what they can to stay afloat (Adams et al. 1985; Dunford and Brennan 1976; Kufeldt and Nimmo 1987). As evidenced by a number of studies, often this means exchanging sex for money, food, shelter, and drugs (see Clatts and Davis 1996; Kipke et al. 1995; Rotheram-Borus and Koopman 1989). Psychological problems among these youths include developmental delay, chronic depression, suicidal ideation, and past attempts at suicide (Caton 1986; Deykin et al. 1987). The constellation of risk behaviors results in exceptional vulnerability to poor health outcomes, particularly sexually transmitted diseases, hepatitis, unplanned pregnancies, HIV infection, and accelerated immune dysfunction associated with AIDS (Futterman et al. 1993; Hein 1988;Stricofetal. 1991; Yatesetal. 1988). There is limited empirical information available about the nature of this complex and "hidden" population or the distribution of risk behaviors within it and, hence, little empirical basis for the development of critical prevention strategies and policies. In this report we construct a demographic and behavioral profile of the homeless youth population in New York City and examine the significance of patterns of drug abuse and high-risk sexual behavior in this population in relation to risk for HIV infection. Background and Methods Historically, the homeless youth population in New York City was thought to be composed primarily of "runaway youth." In fact, however, and in contrast to other major homeless youth populations in Los Angeles and San Francisco, most of the youth on the streets in New York City are originally from the New York metropolitan area. Moreover, contrary to popular images of "runaways," substantial numbers are "castaways" and "throwaways," those who are homeless because their families have become homeless, those who have left foster care or group homes, and those who are homeless due to neglect and abandonment. Most of the available information about this population is derived from quasiinstitutional samples recruited in homeless shelters, foster care, drug treatment programs, and the criminal justice system. The inferences that can be drawn from such data are limited. Many on the streets do not utilize shelter and treatment services and, hence, are not represented in these samples. Similarly, while these

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young people may be somewhat more likely than those in the general population to eventually become involved with the criminal justice system, they may not be identified within that system as homeless. Hence, data from these institutions are also not representative. An additional limitation stems from the fact that young people in all of these institutional settings often conceal their involvement in highrisk behaviors because of fear of stigma and of being denied services. In order to overcome these limitations, a "purposive," street-based sampling procedure was developed, based on ethnographic research in the natural settings in which street youths are known to congregate in the course of their participation in the street economy. These settings include bus and train stations, prostitution strolls, areas in and around pornography shops, "hustler" bars, and public sex venues where youths are known to exchange sex (Clatts et al. 1995). Unlike adult homeless populations and even street youth populations in some other geographic areas, homelessness among New York City street youth is often a process that occurs over an extended period of time rather than as the result of an abrupt break. For this reason, the sample was purposely constructed to include a broad population with unstable housing. Those included in the sample were between the ages of 12 and 23 and were homeless and/or known to be dependent upon the street economy as their primary means of economic support. The street economy not only includes illegal activities like drug dealing and prostitution, but also quasi-legal activities like panhandling. Structured survey interviews were conducted with 929 street youths between February 1993 and July 1994. The refusal rate was less than 10 percent. A small number of individuals were found to have been interviewed more than once, and second interviews were eliminated from these analyses. Descriptive statistics were generated by a frequency analysis. Chi-square analyses were used to compare demographic and behavioral variables with HIV risk. Higher-level analyses, such as proportional hazard or multiple regression, were not employed because our primary interest in this report is to demonstrate the number of factors involved in these youths' risk profile (as opposed to showing the relative proportions of individual risks). Demographic Characteristics and Behavioral Profile Demographic Composition Nearly three-quarters (74 percent) of the sample were male and one-quarter was female (26 percent). Only 3 percent were under the age of 15. Sixteen percent were 16 to 17 years of age. Thirty-four percent were 18 to 19 years of age. Twentyseven percent were 20 to 21 years of age. Twenty percent were 22 to 23 years of age. The sample was fairly evenly divided among racial/ethnic groups, including whites (32 percent), blacks (29 percent), and Hispanics (30 percent). Nine percent were identified as mixed or as some other racial group. Contrary to popular media images of runaways lured from distant rural areas by the lights and glitter of Times Square, over one-half (54 percent) were from the New York City metropolitan area. Only 30 percent were from other U.S. states, 11 percent were from the Caribbean (including Puerto Rico), and 5 percent were from other geographic areas. Approximately two-thirds (63 percent) described themselves as heterosexual.

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Roughly one-third described themselves as gay or lesbian (11 percent) or bisexual (24 percent), and a small number (2 percent) declined to specify a sexual identity category. These data probably underrepresent the actual prevalence of sexual minorities in this population: Adolescents often do not yet have a fixed sexual orientation, and questions about sexual identity are especially prone to social desirability bias, particularly in populations such as this, which are exposed to high levels of sexual exploitation in the context of sex work.

Homelessness
At the time of the interview, almost one-half (47 percent) of the sample were chronically homeless, defined as living in a squat (quasi-communal living in abandoned buildings) or sleeping in a subway car or train tunnel, in a park, or in an abandoned building. Of those who were currently homeless, over two-thirds (67 percent) had been homeless for at least one year. Others in the sample derived their primary needs (food, clothing, shelter) from the street economy but may not have been literally homeless at the time of the interview. In some cases, these were young people beginning to move into homelessness, still staying at home on some nights but spending increasing time away from home with no contact with family members. Still others described having a place to sleep at the time of the interview, but also that they had slept on the streets in the recent past and were uncertain about how long they would be able to stay in their current housing arrangement. The general profile then is of literal homelessness as well as chronic housing instability. Places in which survey respondents had spent at least one night in the past year included: relative's home (4 percent), boyfriend's or girlfriend's home (28 percent), friend's home (46 percent), paying sex partner's home (10 percent), foster or group home (13 percent), "halfway house" (7 percent), shelter or mission (35 percent), motel or boarding house (20 percent), on the street or subways (38 percent), in an abandoned building or squat (37 percent), in prison or jail (29 percent), in a park (27 percent), on a beach (12 percent), or in a car or bus (15 percent). Sources of Income A question about education was added to the last round of surveys (n = 260). Only 21 percent of those responding to this question had been in school during the last semester and only 9 percent had graduated from high school or received a General Equivalency Diploma. Thus, with limited education and few marketable job skills, these youths have very limited access to stable sources of legal income. Moreover, the kinds of activities available to them within the illegal street economy are situationally unstable, often only generate small amounts of cash at a time, and vary in productivity according to both short-term and long-term cycles in the street economy. Consequently, they rely upon multiple "hustles" within both the formal and informal economy. Nearly one-third (28 percent) reported some form of legal employment (usually some type of short-term day labor). Some got money from a parent or relatives (30 percent), from friends (26 percent), from a boyfriend or girlfriend (19 percent), or some form of public assistance (23 percent). Most were involved in multiple activities within the street economy, including panhandling (37 percent), prostitution (25 percent), distribution of illegal drugs (24 percent),

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pimping (2 percent), pornography (3 percent), mugging (8 percent), and stealing (19 percent). It is important to recognize that many of these activities are interdependent. For example, more than one-third obtained money from panhandling, typically involving an open solicitation for "spare change," which is often used as a pretext for sex trade. It should also be noted that sex trade in this population is often less "commodified" than in adult populations, and owing to the stigma attached to it, many youths do not acknowledge a "prostitute" identity. Therefore, the figure on prostitution (25 percent) probably substantially underrepresents actual prevalence of sex for money or goods (shelter, drugs, etc.). One-fourth in the sample earned money through the sale and distribution of illegal drugs, a figure that may also underrepresent actual prevalence of drug distribution. Knowledge of how and where to access drugs and to obtain drugs for sex partners is closely interwoven with street youths' own use of drugs and their participation in sex trade (Clatts 1999). However, they may not view themselves as being involved in "drug dealing," even if their interactions involve transactions based on sex and drug trade. Sexual Activity Four-fifths of the sample (82 percent) were sexually active. About one-half (51 percent) had had sex with a "main partner" in the last 30 days (some with a regular commercial sex partner) and about one-half (49 percent) had had sex with multiple partners in the last 30 days. One-third (33 percent) had had sex with a main partner only in the last 30 days, one-third with multiple partners only (31 percent), and roughly one-fifth (18 percent) with both main and multiple partners. Twenty percent of the sample had had sex with four or more partners in the 30 days prior to interview. Nearly one-half (44 percent) had had unprotected sex with a main partner in the last 30 days, including vaginal sex (70 percent), anal sex (59 percent), and oral sex (87 percent). Well over one-third (38 percent) had had unprotected sex with multiple partners in the last 30 days, again including vaginal sex (53 percent), anal sex (37 percent), and oral sex (71 percent). Over one-quarter (28 percent) had had a sexually transmitted disease at some point in their lives, although this figure may underestimate actual STD rates, since street youths often go undiagnosed and untreated. Those in the sample were found to be very knowledgeable about how HIV infection is transmitted, as well as how risk for transmission can be reduced. In comparing HIV knowledge and self-reported behavior, they were also found to be good predictors of their own potential risk. Yet nearly one-half thought that it was "somewhat likely" (35 percent) or "very likely" (10 percent) that they would become HIV infected, and 2.3 percent spontaneously disclosed that they already had HIV infection or AIDS. Use of Illegal Drugs Street youths use a wide variety of illegal drugs. Most in the sample had used marijuana (71 percent) and alcohol (77 percent) at some time in their lives. Twenty-six percent used marijuana on a daily basis and 26 percent used alcohol on a daily basis. Over two-thirds of the sample (68 percent) had had some type of lifetime exposure to use of illegal drugs, 11 percent had used one drug, 9 percent had

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used two drugs, and nearly one-half (48 percent) had used three or more drugs. Types of drugs used included crack-cocaine (smoke) (36 percent), cocaine (53 percent), heroin (58 percent), amphetamines (32 percent), and psychedelics (51 percent). Current drug use was also quite high: Noninjected drugs used within the 30 days prior to the interview included crack (12 percent), cocaine (18 percent), heroin (13 percent), and speedballs (heroin/cocaine) (3 percent). Drugs injected within the 30 days prior to the interview included crack (1 percent), cocaine (10 percent), heroin (15 percent), speedballs (6 percent), and amphetamines (2 percent). Of those who had injected drugs, nearly one-half (49 percent) had shared syringes, and the vast majority (81 percent) had shared other injection paraphernalia such as cookers, cotton, and rinse water, which has been implicated in the spread of blood-borne pathogens (cf. Clatts et al. 1998). Less than one-quarter (24 percent) had ever been in drug treatment. Correlates of HIV Risk Drug and sex-related risk behaviors were common throughout the sample but were distributed differently across subgroups. For example, multiple-partner unprotected sex (deriving primarily from economic dependency on commercial sex work) was significantly associated with age (19-23 years of age;/? < .001), gender (male; p < .001), sexual orientation (gay/bisexual; p < .001), and housing status (homeless; p < .01), as well as the use of a wide range of drugs. Such use included a history of having injected drugs (p < .001), current use of injected drugs (p < .001), and current use of crack (p < .001). Homelessness was associated with sex work (p < .001), unprotected multiplepartner sex (p < .01), and a history of STDs (p < .001). Drug use (within the 30 days prior to interview) was three times more likely among those who were homeless, regardless of the type of drug examined, including alcohol (p < .001), crack (p < .001), and a wide range of injected drugs (p < .001). T-tests indicate that homelessness and economic dependence on sex work strongly predicted use of multiple types of drugs (p < .0001). Street youths who reported having had an STD were more likely to have slept at least one night in the past year with a paying sex partner (p < .001) or in parks or on streets (p < .01). They also were more likely to have participated in the street economy (p < .001), to have been incarcerated in the last year (p < .01), to be involved in prostitution (p < .001), pornography (p < .01), and mugging or stealing (p < .001), and to be chronic users of cocaine and crack (p < .001). The probability of engaging in one or more HIV risk behaviors significantly increased among older street youths. Reported behaviors included having injected drugs at some point in their lifetime (p < .001), having injected in the last 30 days (p < .01), having unprotected sex with multiple partners at some point in their lifetime (p < .001), and having unprotected sex with a main partner at some point in their lifetime (p < .05) (many sex partners also being street youths at high risk for HIV). Other HIV-related factors also significantly increased with age, including homelessness (p <.06) prostitution (p < .001), ever having an STD (p < .001), use of crack (ever) (p < .001), and current use of crack (last 30 days) (p < .001). These data suggest that cumulative risk significantly increases with age. The issue of age is a critical one because prevention services for street youths are often focused on

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younger segments of the population and access is curtailed as chronological adult age is achieved. Indeed, older youths were least likely to report having had contact with prevention services. This contradiction between age-associated need and agedefined eligibility is a function of the structure of existing funding streams that assume older youths can and should be "transitioned" to adult services and that limit the services available to older street youths (Clatts et al. 1998). Yet developmental delays associated with exposure to chronic violence and victimization are quite common among these youths, thus resulting in a poor "fit" between chronological age and developmental maturity. Few are effectively transitioned to adult services. Left to the vagaries of the street economy, many remain functionally outside the purview of public services until they appear in a hospital emergency room with acute injury or illness or until their involvement in the street economy has escalated to the point at which it results in criminal arrest and imprisonment. Conclusion This report has provided a demographic and behavioral profile of street youth in New York City. Data show that street youths are involved in multiple risk behaviors, including chronic, high-risk drug abuse, as well as high-risk sexual behavior. This is but one local example of the emerging "class" of adolescents and young adults, one that is notably overrepresented among ethnic and sexual minority groups, who are "coming of age" in the burgeoning drug and sex economies now flourishing throughout areas of North and Central America, Southeast Asia, Western Europe and Eastern-bloc nations, and the former Soviet Union. The confluence of drug and sex risk among street youth worldwide is of particular concern in relation to HIV infection because several segments within this population interact behaviorally with two other high-exposure populations: adult gay men, in the context of commercial sex work, and adult IV drug injectors, in the context of high-risk drug injection practicesboth populations with high background seroprevalence (Des Jarlais et al. 1994; Siegel et al. 1988). Situated at a behavioral "crossroads," street youths form an epidemiological bridge between these high-exposure populations because the youths' drug and sexual risk behaviors frequently include individuals from one or both groups (Battjes et al. 1994; Chu et al. 1992; Edlin et al. 1994). Although street outreach services have been shown to be an effective means of educating street youths about risk for HIV infection, and the use of the Harm Reduction Model has proven to be an especially powerful tool in attracting them to social and public health services, retaining them in services, and promoting healthseeking behaviors (Clatts et al. 1997), existing resources for prevention services targeted to this population are woefully inadequate relative to the scope of the population and the complexity of these youths' needs. In particular, there is an urgent need to expand and integrate street outreach, shelter, drug treatment, and primary health care services, and to do so within a unified service-delivery model (Clatts et al. 1997) that is responsive to the individual needs and capacities of youths within this complex and growing high-risk population.

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NOTES

Acknowledgments. Data reported in this article are derived from a study supported by grant #U62/CCU207192-01 from the Centers for Disease Control. Research was conducted under a collaborative agreement between Victims Services Agency, National Development and Research Institutes, Inc., the Hetrick-Martin Institute, the Community Health Project, the Center for Children and Families, and the AIDS and Adolescents Network of New York. Additional ethnographic research was supported by grant #00214-16-RG from the American Foundation for AIDS Research. We would like to acknowledge the support of Richard Haymes, Helene Lauffer, Teri Lewis, John Santelli, and Mary Washburn. Views expressed are our responsibility and do not necessarily represent the position of any of the aforementioned individuals or institutions. Correspondence may be addressed to the authors at Youth at Risk Project, National Development and Research Institutes, Inc., Two World Trade Center, 16th Floor, New York, NY 10048.
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