Sexual health, vulnerabilities and risk behaviours among homeless adults

Sexual health as a concept has evolved over the past decades by widening its original biomedical focus to include emotional, cognitive, physical and social aspects of sexual wellbeing, and a positive integration of sexuality into a person’s life.^1–3 According to the US Surgeon General, sexual health ‘includes the ability to understand and weigh the risks and impacts of sexual actions and to practice abstinence when appropriate. It includes freedom from sexual abuse and discrimination and the ability of individuals to integrate their sexuality into their lives, derive pleasure from it, and to reproduce if they so choose’.² It has been suggested that such definitions are aspirational goals rather than a reflection of most people’s current conditions.⁴ This may be especially true for homeless individuals, who lack the privacy of a home and whose sexual decision-making may be affected by poverty and many other vulnerabilities.

Here, we describe sexual health-related factors in a sample of 500 homeless individuals from Vancouver, Victoria and Prince George, British Columbia, Canada. Recruitment and procedures have been described in detail elsewhere.⁵ The interview assessed: demographic information; childhood sexual abuse,⁶ adult sexual abuse, current sexual risk-taking behaviours and sexually transmissible infections (STIs). We calculated a summary score for factors that compromise sexual health: childhood and adult sexual abuse, sex work and unprotected sex with more than one partner, resulting in scores of 0 to 4.

Of the 500 individuals, 196 (39.2%) were women; participants ranged in age from 19–66 years, with a mean age of 37.9; 39.8% identified as Aboriginal; 63.6% had not graduated from high school; 64.5% (n = 320) were single or had never married; and 2.8% (n = 314) had children. Eight women reported being pregnant. Table 1 presents their sexual vulnerability factors stratified by gender.

Table 1.  Sexual vulnerabilities and risk factors
CI, confidence interval

In total, 58.9% (n = 294) of the participants reported having been sexually active in the past month and 7.2% (n = 36) of them had had unprotected sex with at least two persons. Significantly more women than men reported this type of behaviour. The number of instances of unprotected sex in the last 30 days varied greatly from 0 to 100 times, with a median of 3 (interquartile range Q1–Q3: 0–12). Regarding STIs, 8.2% (n = 16) of the women and 7.3% (n = 22) of the men reported having been diagnosed with HIV/AIDS (P = 0.726, 95% confidence interval: 5.5–10.3%), and 7.1% (n = 14) of the women and 3.7% (n = 11) of the men had been diagnosed with at least one other STI in the past 12 months (P = 0.082). When summarising sexual vulnerability factors, more than one-quarter of the participants had two or more factors, and women had a greater number of factors than men.

Although the Canadian government has developed a framework to provide accessible sexual health education,⁷ it also indicated a lack of specific sexual health strategies due to a lack of Canadian data.⁸ Position papers on sexual health discuss sexual rights in the context of human rights.³ With this in mind, one of the most concerning findings of our study are the high rates of childhood and adult sexual abuse. Childhood sexual abuse is consistently associated with a myriad of negative outcomes in adulthood⁹ including psychological sequelae such as low self-esteem, depression, and anxiety,¹⁰ sexual risk behaviours and revictimisation.^11–13 Homelessness is associated with health inequities¹⁴ and compromises sexual health fundamentally. Homeless individuals have no access to safe or private spaces to engage in pleasurable sexual activities. They may enter into an intimate relationship exchanging sex for shelter, which, for women, often introduces or stabilises a gendered power imbalance.¹⁵ Sex workers are forced to work in public spaces, which has been shown to be associated with an increased risk of coercive unprotected sex.¹⁶

A substantial number of participants engaged in sex work. Sex work and unprotected sex with multiple partners have been identified as major risk factors for HIV-transmission.^17–19 Overall, few individuals reported recent unprotected sex with more than one person, confirming the data of a study among female injection drug users from Vancouver and Toronto.²⁰ Summarising all vulnerability factors, our data indicate that a significant proportion of individuals and more women than men reported multiple experiences that compromise their sexual health exponentially.

It is difficult to imagine that positive sexual experiences free of coercion occur while living on the street. Programs that support the prevention of violence to address the high rates of sexual abuse found in our study are necessary. Housing interventions – in the sense of an unconditional prerequisite without requiring certain behaviours such as abstinence from substance use or sex work – seem absolutely essential for promoting the sexual health of homeless individuals. Housing offers a private space for living that increases the likelihood of engaging in consensual sex, decreases the risk of sexual victimisation on the streets and provides a precondition for the recovery of traumatic experiences.

None declared.