Title: Sex Work and Sex Exchange Among Street Children: An Urgent Need for a Global Response
Abstract: See Related Article p. 222 See Related Article p. 222 The article published by Towe and colleagues [[1]Towe V.L. ul Hasan S. Zafar S.T. Sherman S.G. Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan.J Adolesc Health. 2009; 44: 222-228Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar] in this month's Journal serves as a call to action for researchers and policymakers to address an understudied phenomenon among a neglected population. Studies from settings around the world have established that street children experience a wide range of human immunodeficiency (HIV)–related risks and harms [2Inciardi J.A. Surratt H.L. Children in the streets of Brazil: Drug use, crime, violence, and HIV risks.Subst Use Misuse. 1998; 33: 1461-1480Crossref PubMed Scopus (58) Google Scholar, 3Sherman S.S. Plitt S. ul Hassan S. et al.Drug use, street survival, and risk behaviors among street children in Lahore.Pakistan. J Urban Health. 2005; 82: 113-124Google Scholar, 4Kissin D.M. Zapata L. Yorick R. et al.HIV seroprevalence in street youth, St. Petersburg.Russia. AIDS. 2007; 21: 2333-2340Crossref PubMed Scopus (65) Google Scholar], often as a result of social, familial, and economic discrimination and exclusion. Sadly, for many street children, the exchange of sex for money, shelter, food, or drugs is a necessary yet perilous survival strategy. These activities often occur in the context of sexual victimization, forced sexual activity, and oppressive power dynamics in which the negotiation of condom use and engagement in other safer sex practices are severely compromised [[5]Tyler K.A. Johnson K.A. Trading sex: Voluntary or coerced? The experiences of homeless youth.J Sex Res. 2006; 43: 208-216Crossref PubMed Scopus (95) Google Scholar]. A history of sexual abuse and other forms of childhood maltreatment are also extremely common among this population [[6]Stoltz J.A. Shannon K. Kerr T. et al.Associations between childhood maltreatment and sex work in a cohort of drug-using youth.Soc Sci Med. 2007; 65: 1214-1221Crossref PubMed Scopus (112) Google Scholar]. Although a similar proportion of both genders have been reported to engage in survival sex work [7Kral A.H. Molnar B.E. Booth R.E. et al.Prevalence of sexual risk behaviour and substance use among runaway and homeless adolescents in San Francisco, Denver and New York City.Int J STD AIDS. 1997; 8: 109-117Crossref PubMed Scopus (140) Google Scholar, 8Greene J.M. Ennett S.T. Ringwalt C.L. Prevalence and correlates of survival sex among runaway and homeless youth.Am J Public Health. 1999; 89: 1406-1409Crossref PubMed Scopus (304) Google Scholar], some research suggests that distinct HIV-related risk factors exist for males and females [9Haley N. Roy E. Leclerc P. et al.HIV risk profile of male street youth involved in survival sex.Sex Transm Infect. 2004; 80: 526-530Crossref PubMed Scopus (104) Google Scholar, 10Weber A.E. Boivin J.F. Blais L. et al.HIV risk profile and prostitution among female street youths.J Urban Health. 2002; 79: 525-535Crossref PubMed Scopus (52) Google Scholar]. Although the number of North American studies investigating the circumstances and harms associated with survival sex work among street children is limited, research in developing and low-income countries was until recently nonexistent. However, the results published by Towe and colleagues [[1]Towe V.L. ul Hasan S. Zafar S.T. Sherman S.G. Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan.J Adolesc Health. 2009; 44: 222-228Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar] can, and must, be situated within a burgeoning literature demonstrating the commonplace experience of sex work and related harms among street children in Russia [[11]Shakarishvili A. Dubovskaya L.K. Zohrabyan L.S. et al.Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation.Lancet. 2005; 366: 57-60Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar], Brazil [[12]de Carvalho F.T. Neiva-Silva L. Ramos M.C. et al.Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil.AIDS Behav. 2006; 10: S57-S66Crossref PubMed Scopus (53) Google Scholar], and Nigeria [[13]Olley B.O. Social and health behaviors in youth of the streets of Ibadan, Nigeria.Child Abuse Negl. 2006; 30: 271-282Crossref PubMed Scopus (74) Google Scholar]. The proportion of street children who report ever exchanging sex in these settings varies between 10% and 50%, findings that mirror similar studies conducted in Canada [9Haley N. Roy E. Leclerc P. et al.HIV risk profile of male street youth involved in survival sex.Sex Transm Infect. 2004; 80: 526-530Crossref PubMed Scopus (104) Google Scholar, 10Weber A.E. Boivin J.F. Blais L. et al.HIV risk profile and prostitution among female street youths.J Urban Health. 2002; 79: 525-535Crossref PubMed Scopus (52) Google Scholar] and the United States [8Greene J.M. Ennett S.T. Ringwalt C.L. Prevalence and correlates of survival sex among runaway and homeless youth.Am J Public Health. 1999; 89: 1406-1409Crossref PubMed Scopus (304) Google Scholar, 14Kipke M.D. O'Connor S. Palmer R. et al.Street youth in Los Angeles. Profile of a group at high risk for human immunodeficiency virus infection.Arch Pediat Adol Med. 1995; 149: 513-519Crossref PubMed Scopus (164) Google Scholar]. In many of these settings, injection drug use in the absence of harm reduction programs (e.g., needle exchange) and a reliance on sex work in deprived, impoverished environments has and will likely continue to contribute to explosive epidemics of HIV in previously low-prevalence youth populations [4Kissin D.M. Zapata L. Yorick R. et al.HIV seroprevalence in street youth, St. Petersburg.Russia. AIDS. 2007; 21: 2333-2340Crossref PubMed Scopus (65) Google Scholar, 15Roy E. Haley N. Leclerc P. et al.HIV incidence among street youth in Montreal, Canada.AIDS. 2003; 17: 1071-1075Crossref PubMed Scopus (39) Google Scholar]. The analyses presented this issue of the Journal paint a particularly worrisome picture of the dire situation in which many of the male street children in Lahore, Pakistan, find themselves. Although the median age of the sample was less than 14 years old, more than 40% reported exchanging sex in the past 3 months. Of particular concern was that only two thirds had ever heard of condoms, and among those who had, condom use was alarmingly low. However, males who had engaged in sex work were more likely to have ever heard of HIV/acquired immune deficiency syndrome (AIDS). These findings raise a number of important questions that require urgent attention from researchers, policymakers, and health care professionals who work to improve the health and well-being of these highly marginalized individuals. Although a massive increase in resources for evidence-based HIV and safer sexual education programs is undoubtedly required, it is unclear what can be expected from improved knowledge alone. As research expands beyond the boundaries of resource-rich settings, we must ask ourselves whether education programs and condom distribution are enough. As the authors state in their discussion of possible interventions for this population, “any education meant to affect behavioral changes should be nested within an intervention that is aimed at improving the overall quality of life for these children” [[1]Towe V.L. ul Hasan S. Zafar S.T. Sherman S.G. Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan.J Adolesc Health. 2009; 44: 222-228Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar]. What do these interventions look like, and what is required of decision makers and organizations to implement them? Is it possible for any one intervention to address the myriad of social, cultural, and economic factors that structure and produce the conditions in which street children must turn to sex work for survival? Can attempts to reduce risk activity succeed in the absence of local, national, and global commitments to address the impoverished conditions, barriers to education, and social inequities so pervasive in the lives of street children around the globe? The article by Towe and colleagues [[1]Towe V.L. ul Hasan S. Zafar S.T. Sherman S.G. Street life and drug risk behaviors associated with exchanging sex among male street children in Lahore, Pakistan.J Adolesc Health. 2009; 44: 222-228Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar] points to the need for more research to identify and evaluate effective strategies for preventing engagement in exchange sex and reducing the harms associated with it. Research and policy intervention involving the clients of young sex workers is also required to remove the onus on street children to negotiate safer sex and to determine how we may reduce the exploitation of highly vulnerable sex-working children. It is our hope that the work presented by Towe and colleagues is yet another push toward an effective global response to address survival sex work among minors. As we approach the 20th anniversary of the 1989 United Nations Convention on the Rights of the Child, the time is right for the adolescent health community to call for—indeed demand—commitments from every level of government to identify evidence-based solutions to prevent the exchange of sex by children.