Lloyd A Goldsamt

Abstract

"Hustling" or sex work is a common means of surviving on the streets and paying for drugs among homeless youth. In this article, we formulate the concepts of "street capital" and "street competencies" to describe how 10 young men who have sex with men (YMSM) in New York City accumulated various knowledge and skills throughout their childhood and adolescence, and later entered into homelessness and the street economy as sex workers. While half of these young men described themselves as gay or bisexual, sexual identity was not a primary consideration amongst these youth. All were homeless and/or users of illegal drugs, and all survived through intimate involvement in the "street economy" - an informal system of exchange that circulates drugs, sex, and money across a range of settings and participants. Based upon an analysis of life history accounts gained through ethnographic interviews, we describe common pathways into the street economy with an emphasis on understanding how these 10 young men of diverse backgrounds became involved in homelessness, drugs, and sex work. In doing this, we document the differential sources of knowledge and particular childhood experiences that launched these youth into coherent street careers.

Abstract

Purpose To examine relationships among childhood adversity, attachment style (one's core beliefs regarding the self and others), and the following risk behaviors and contexts among young men who have sex with men (YMSM): homelessness, daily substance use, participation in sex work, involvement in the criminal justice system, and being out of school or work. Methods Using a targeted sampling approach, we recruited 569 YMSM aged 17-28 years from natural venues in New York City including bars, clubs, parks, and bus stations. Youth completed a structured interview assessing lifetime and current risk and protective contexts and behavior. Data were analyzed using univariate and multivariate statistical methods, including hierarchical logistic regression. Results After controlling for demographic characteristics and childhood adversity, YMSM with a fearful attachment style were more likely to have been homeless (OR 2.93, 95% CI 1.65-5.18), to have participated in sex work (OR 2.35, 95% CI 1.44-3.85), to use substances daily (OR 2.79, 95% CI 1.29-6.03), to have been involved in the criminal justice system (OR 2.04, 95% CI 1.38-3.01), and to be out of school/work (OR 2.47, 95% CI 1.47-4.15). Three subgroups were particularly vulnerable: YMSM who identified as heterosexual, or bisexual, and/or transgender. Conclusions A fearful attachment style contributes to some YMSM remaining outside of the protective systems of family, school, and work, and is associated with risky contexts where they are less likely to encounter prosocial peers and adults. Further, it is associated with risk behavior. Although gay-identified youth are generally found to have poor outcomes when compared with the general population of adolescents, in the present report, YMSM who identified as heterosexual were at particular risk. Attachment theory can guide interventions by informing how individuals experience relationships and manage developmental transitions.

Abstract

This article examines the behavioral practices and health risks associated with preparing crack cocaine for injection. Using an ethno-epidemiological approach, injection drug users (n=38) were recruited between 1999 and 2000 from public settings in New York City and Bridgeport, Connecticut and responded to a semistructured interview focusing on crack injection initiation and their most recent crack injection. Study findings indicate that methods of preparing crack for injection were impacted by a transforming agent, heat applied to the "cooker," heroin use, age of the injector, and geographic location of the injector. The findings suggest that crack injectors use a variety of methods to prepare crack, which may carry different risks for the transmission of bloodborne pathogens. In particular, crack injection may be an important factor in the current HIV epidemic.

Abstract

The cumulative epidemiologic literature indicates that many injecting drug users (IDUs) initiate injection as a mode of drug administration during late adolescence or early adulthood. Recent studies have shown that IDUs are often exposed to viral infections relatively early in the course of injection, highlighting the importance of understanding this initiation process for both epidemiology and prevention. Epidemiologic evidence similarly suggests that at least some youth populations, most notably young men who have sex with men (YMSM), are at substantial risk for exposure to HIV and other sexually transmitted diseases (STDs) from early sexual activity. Despite the importance of this issue for both epidemiology and prevention, however, surprisingly little information is available on the social course of injection initiation, including the individual, social, or ecological factors that might mitigate or exacerbate transmission risks within the critical phase of early injection drug use. Similarly, we know little about the ways that YMSM and other high-risk youth understand risk, the kinds of exchanges and relationships in which they participate in the context of initiating sexual activity, or how drug use is operant in these exchanges and early sexual experiences. In this article, we explore key dimensions of the early initiation of injection and sexual risk, and discuss how a social network approach might be instrumental in understanding the social course of drug injection and sexual activities among youth and young adult populations.

Abstract

Public health, including the prevention of drug use, has long relied upon sentinel marker data obtained from national and regional tracking systems in order to forecast changes in patterns of drug abuse. More recently, these types of data have also played an important role in monitoring particular types of medical consequences associated with drug use, including the spread of HIV, HBV, HCV and other viral infections prevalent in IDU populations. While these types of data may provide an important sources of information about changes in drug use and its consequences, the limits of these sources of data have also become widely apparent. Based on a patchwork of institutionally-derived sources of data (e.g. emergency departments, drug treatment admissions, and law enforcement data on drug seizures and arrests), sentinel marker data typically fail to capture a number of "hidden populations" evidencing "hidden" drug-related risk behaviours. Many of these populations and behavioural practices only become apparent well after they have become diffused across regions and diverse drug user subpopulations, making prevention more difficult and more expensive. Furthermore, these systems cannot capture patterns of episodic use, such as those evidenced in crack injection. Ethnographic methods, including field-based community assessment, semi-structured qualitative interviews, and targeted observation of "natural" venues in which drugs are bought, sold, and used, have the potential to overcome some of the limitations from which "systems data" often suffer. Drawing on an ethno-epidemiological approach, our ongoing multi-site research on the use of injection as a mode of administration in the use of crack cocaine is a case in point, and illustrates the potential utility an ethnographic model for the identification and tracking of emergent and ongoing drug use practices.

Abstract

This pilot study evaluated whether brief safer sex interventions for women partners of male injection drug users significantly influenced perceptions of partner risk, human immunodeficiency virus (HIV) knowledge, correct condom usage, and self-reported consistent safer sex (abstinence or 100% of vaginal-penile intercourse acts protected by male or female condoms). The study also examined the impact of pretest assessment on those variables since pretest assessment may challenge participants' current knowledge, safer sex practices, and partner communication techniques. The study randomly assigned participants to pretest or no pretest assessment. Each group was also assigned randomly to a presentation modality: (1) safer sex pamphlet review only, (2) pamphlet review with demonstration of several safer sex alternatives, or (3) pamphlet review with skills practice to mastery with one safer sex alternative of the woman's choice. For the last two conditions, a 35-minute interactive session covered prevention efficacy of safer sex methods for HIV, sexually transmitted infections, pregnancy, correct use, eroticization, local cost and availability, and partner objections. At 7 weeks postintervention, a higher proportion of women who took pretest assessment reported consistent safer sex (66.7%) compared to those without pretests (55.6%). Assignment to the interactive interventions (skills or demonstration) had little additional impact over pretest assessment for these women. Among women who did not take pretests, the interactive interventions had strong effects; 76.9% reported consistent safer sex versus 33.3% in the pamphlet review group. There were additional specific effects for pretest assessment on HIV knowledge and partner risk perception and for interactive intervention on correct condom usage. Brief interventions appear to have some positive short-term effects. Pretest assessment may be an important component of brief interventions.

Abstract

In response to recent concerns about risk of HIV-1 transmission from drug injection paraphernalia such as cookers, ethnographic methods were used to develop a descriptive typology of the paraphernalia and practices used to prepare and inject illegal drugs. Observational data were then applied in laboratory studies in which a quantitative HIV-1 microculture assay was used to measure the recovery of infectious HIV-1 in cookers. HIV-1 survival inside cookers was a function of the temperature achieved during preparation of drug solutions; HIV-1 was inactivated once temperature exceeded, on average, 65°C. Although different types of cookers, volumes, and heat sources affected survival times, heating cookers 15 seconds or longer reduced viable HIV-1 below detectable levels.

Abstract

Effective HIV intervention, and its evaluation, requires close collaboration between community members and researchers. This article explores our experience as white, middle-class researchers in poor, inner city, multicultural neighborhoods. Research role demands put us at an automatic distance from our respondents, clients, and community membersources of valuable information for design and evaluation of interventions. Distance is further compounded by differences in culture, mutual stereotypes, and the history of the research enterprise in these and similar communities. Strategies for reducing distance include methods for undoing stereotypes, emphasizing research as a joint enterprise, stressing fairness, learning about the contexts within which the community functions, and assessing and addressing immediate community needs. The authors provide examples from their own experiences creating and maintaining collaborative HIV interventions and their evaluation. A discussion is included of the ways in which the researchers have been educated by the community to correct misperceptions and false expectations of what HIV work in the community would entail. The article concludes with a discussion of effective HIV prevention messages and their delivery.

Abstract

Demonstration sessions of cognitive therapy (Beck), cognitive behavior modification (Meichenbaum), and short-term psychodynamic therapy (Strupp) with the same patient, Richard, were compared. These therapies were analyzed using the Coding System of Therapeutic Focus, a recently developed system to analyze therapist statements in a language that is neutral with respect to psychotherapy orientation. In comparison to the other therapists, Beck focused more on the cognitive triad of Richard's thoughts about self, world, and future. Although all three therapists placed a comparable emphasis on the impact that other people had on the patient, both Meichenbaum and Strupp focused more than Beck on the impact Richard may have had on others.

Abstract

Using a coding system designed to assess therapists’ in-session focus, we conducted a preliminary investigation of the differential emphasis placed on client’s intrapersonal and interpersonal functioning with interim data collected from an outcome study of a cognitive—behavioral (prescrip-tive) therapy and psychodynamic—interpersonal (exploratory) therapy. Consistent with theory, exploratory therapists made more interpersonal links relative to intrapersonal links. Contrary to theoretical expectation, there was a tendency for prescriptive therapists to place more of a focus on interpersonal, rather than intrapersonal, links. A between-group com-parison revealed that there was no difference between the therapies in their emphasis on intrapersonal or interpersonal links. However, only in exploratory therapy were there positive correlations approaching statis-tical signilicance between the focus on interpersonal links and clienfs improvement in self-esteem and social adjustment. There was also a marginally significant positive correlation between prescriptive therapists’ focus on intrapersonal links and symptom improvement. Although the findings suggest differential mechanisms of change across these two therapeutic orientations, the results should be interpreted cautiously until they can be replicated with a larger sample.