Substance Abuse and Mental Health Correlates of Victimization Classes among Homeless Youth

Background

Literature demonstrates that street victimization is a common occurrence among homeless youth.¹ Street victimization is correlated with poorer mental health, including substance abuse,^2,3 depressive symptoms,³ and posttraumatic stress disorder (PTSD).⁴ Despite much research on street youth victimization, few studies have examined victimization classes and how those classes differ by type and frequency of victimization. In two separate studies, authors Bender, Thompson, Ferguson, and Langenderfer relied on latent class analysis to determine subgroups of homeless youth based on the youths’ self-reported victimization experiences. The authors then ran analyses to determine which of several variables predict subgroup membership. Study One focused on substance abuse, whereas Study Two focused on mental health.

The Sample

Purposive sampling between March 2010 and July 2011 resulted in a sample of 601 street youth, each served by a homeless youth agency in Los Angeles (n=200), Austin (n=200), or Denver (n=201). The three eligibility criteria were that the youth had to 1) be 18 to 24 years old, 2) have spent at least two weeks away from home prior to the interview, and 3) provide written informed consent. Researchers conducted quantitative retrospective interviews with the youth to assess demographics, victimization experiences, substance use symptoms, and mental health symptoms. Researchers assessed victimization experiences using a revised version of the Traumatic Life Events Questionnaire,⁵ retaining items only if they were relevant to homeless youth. Substance use and mental health variables were assessed by the Mini International Neuropsychiatry Interview (MINI).⁶ Specifically, Study One examined substance abuse and substance dependence correlates of victimization class while Study Two examined depression and PTSD correlates.

Demographics for the total sample are as follows:

• Age: M=20.5 years (SD=1.6)
• Gender: 64% male, 36% female
• Race/Ethnicity: 40% White, 25% Black, 18% Latino, 17% Other
• Primary living arrangement: 50% homeless, 50% temporarily housed
• Met diagnostic criteria for:
• Alcohol Addiction: 49.8%
• Drug Addiction: 59.7%
• Substance Abuse: 36.6.%
• Substance Dependence: 48.5%
• Depression: 31%
• PTSD: 23%
• Number of moves: M=3.5 (SD=3.7)
• Months homeless: M=32.4 (SD=31) = 2.7 years

The Results

Identifying Victimization Classes

In Study One, researchers identified victimization classes using exploratory latent class analysis, grouping youth based on type and frequency of victimization. Researchers ran multiple models, from one to six classes, and used best-fit indices and their abilities to describe distinct patterns in classes to decide on a three-class model: low-victimization, high victimization, and witness classes.

Among youth in the low-victimization class (n=215, 36%) more than 85% never experienced robbery, experienced physical or sexual assault by a stranger, experienced threat of bodily harm, witnessed an assault, or personally overdosed on drugs. Typically, youth in this class experienced lower rates of all types of victimization than both the high-victimization and witness classes.

The high-victimization class (n=136, 23%) reported high rates of both indirect (e.g., witnessing a severe assault) and direct (e.g., physical assault by a stranger) victimization. This class also reported experiencing victimization types rarely reported by either the low-victimization or witness classes, such as physical or sexual assault by an intimate partner and personally overdosing on drugs.

The witness class (n=250, 42%) reported high rates of indirect victimization, such as witnessing severe assault, witnessing a drug overdose, or experiencing the sudden death of a close friend or loved one. Typically, these indirect forms of victimization were experienced only once.

Study One: Substance Abuse

Results of a first multinomial regression model indicate that, compared to low-victims, witnesses are approximately twice as likely to meet criteria for both substance abuse and dependence. Moreover, both substance abuse and substance dependence increased the odds of being classified as a high-victim versus a low-victim. Results of a second multinomial regression model indicate that although alcohol and drug addiction both increase the risk of being classified as a witness or high-victim as opposed to a low-victim, the odds ratios were higher for alcohol than for drugs.

Study Two: Mental Health

Again using multinomial regression, results indicate that youth in the high-victimization and witness classes were nearly twice as likely to experience depression symptoms and nearly three times as likely to experience PTSD compared to youth in the low-victimization class. Researchers found no significant differences in mental health risks between high-victims and witnesses.

The Implications

Street youth classified as witnesses or high-victims demonstrated higher rates of substance abuse, substance dependence, depression, and PTSD than low-victims. Given the distinct experiences of youth in the three classes, it is important that providers screening for victimization among homeless youth assess not only types of victimization, but potential consequences as well, such as substance abuse and mental health problems. Moreover, prevention efforts targeting homeless youth should include victimization prevention education.

For More Information

For more details on how latent classes were determined; how time homeless, primary living situation, and transience impact classification; and expanded implications, refer to the full articles in Child Abuse & Neglect and Journal of Adolescence. Click the links below to learn more about the authors’ work.

Dr. Kimberly Bender

Lisa Langenderfer-Magruder

Citations

Bender, K., Ferguson, K., Thompson, S., & Langenderfer, L. (in press). Mental health correlates of victimization classes among homeless youth. Child Abuse & Neglect.

Bender, K., Thompson, S.J., Ferguson, K., & Langenderfer, L. (2014). Substance use predictors of victimization profiles among homeless youth: A latent class analysis. Journal of Adolescence, 37(2), 155-164. doi: 10.1016/j.adolescence.2013.11.007

References

1 Stewart, A.J., Steiman, M., Cauce, A.M., Cochran, B.N., Whitbeck, L.B., & Hoyt, D.R. (2004). Victimization and posttraumatic stress disorder among homeless adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 43(3), 325-331.

2 Hoyt, D.R., Ryan, K.D., & Cauce, A.M. (1999). Personal victimization in a high-risk environment: Homeless and runaway adolescents. Journal of Research in Crime and Delinquency, 36(4), 371-392

3 Whitbeck, L.B., Hoyt, D.R., & Bao, W. (2000). Depressive symptoms and co-occurring depressive symptoms, substance abuse, and conduct problems among runaway and homeless adolescents. Child Development, 71(3), 721-732.

4 Whitbeck, L.B., Hoyt, D.R., Johnson, K.D., & Chen, X. (2007). Victimization and posttraumatic stress disorder among runaway and homeless adolescents. Violence and Victims, 22(6), 721-734.

5 Kubany, E. S., Leisen, M. B., Kaplan, A. S., Watson, S. B., Haynes, S. N., Owens, J. A., Burns, K. (2000). Development and preliminary validation of a brief broad-spectrum measure of trauma exposure: The Traumatic Life Events Questionnaire. Psychological Assessment, 12(2), 210-224. doi: 10.1037/1040-3590.12.2.210

6 Sheehan, D., Lecrubier, Y., Sheehan, K., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. (1998). The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22-33.

A Cautionary Tale: Risk Reduction Strategies among Urban American Indian/Alaska Native Men Who Have Sex with Men

American Indian/Alaska Native (AIAN) men who have sex with men (MSM) are at high risk for transmitting and contracting HIV,¹ in part due to sexual risk behavior² and drug injection among this population. Among urban AIAN MSM, HIV prevalence rates range from 18-34%.^2-4 Though there is no empirically supported HIV prevention intervention intended for AIAN MSM,⁵ there are several risk reduction strategies that the general population of MSM use to protect against the transmission of HIV. Pearson and colleagues conceptualize these strategies as a hierarchy, from most to least effective:

1. Not engaging in anal intercourse
2. 100% condom use during anal intercourse
3. Serosorting: Having unprotected anal intercourse (UAI) in a monogamous relationship with a partner who is of the same HIV status (seroconcordant)
4. Serosorting: Engaging in UAI with a seroconcordant casual partner
5. Strategic positioning:  HIV-seropositive partner practices receptive anal sex and HIV-seronegative partner practices insertive anal sex

Given that none of the existing studies addresses AIAN MSM specifically, Pearson and colleagues examined HIV risk reduction strategies among a sample of AIAN MSM, paying particular attention to sexual behavior and risks by serostatus.

Methods and Sample

The authors conducted a secondary data analysis using data from the HONOR project.^{2, 6-8} Between July 2005 and March 2007, researchers recruited AIAN MSM from seven disparate U.S. cities: Seattle-Tacoma, San Francisco-Oakland, Los Angeles, Denver, Tulsa-Oklahoma City, Minneapolis-St. Paul, and New York. Criteria for inclusion included: English-speaking adults (18 or older) residing, working, or socializing in one of the seven study sites. Additional eligibility criteria included identifying as 1) AI, AN, or First Nations and either be enrolled in their tribal nation or report 25% or more Indian blood; and 2) gay, lesbian, bisexual, transgender, or two-spirit (GLBT-TS) or have engaged in same-sex sexual behavior in the previous year. The final analytic sample included 174 anatomically male, AIAN MSM who knew their HIV serostatus. Measures included HIV status; sociodemographic characteristics (e.g., age, gender, partnership status); sexual behavior (e.g., sex trade, sexually transmitted infections, condom use); and risk reduction behaviors. Select sample demographics are as follows:

• Age: M=39.3 year (SD=10.2)
• 28.7% were in monogamous relationships
• 87.9% had at least a high school diploma
• 49.4% were employed
• 52.3% earned less than $1,000 per month

Results

Thirty-five percent of the total sample reported a HIV-seropositive status. Nearly 95% of the total sample reported engagement in some risk reduction strategy, including no anal sex (28%), 100% condom use (23%), and seroconcordant monogamous relationships (8%). Of the men who reported any type of anal sex in the past year, those in serodiscordant relationships (i.e., one partner is HIV-seropositive and the other is HIV-seronegative) were significantly less likely (52.4%) to share their HIV status to all partners than those in seroconcordant relationships (85.5%). Participants in serodiscordant relationships were also more likely than their seroconcordant counterparts to have ever had a sexually transmitted infection, have ever traded sex for money or drugs, be HIV-seropositive, and have more sexual partners.

Implications

Only approximately half of the present sample reported risk reduction strategies that are likely to protect against HIV transmission, such as condom use and monogamous seroconcordant relationships. While some MSM engage in sero-adaptive strategies, such as serosorting or strategic positioning, the protection these strategies offer is likely ineffective when other factors are taken into account. For example, only half of the sample shared their HIV status with partners and only 39% had an HIV test in the past three months; this may create a false confidence and, thus, reduce engagement in HIV prevention behaviors.^9-11 Pearson and colleagues suggest public health messages targeted at AIAN MSM should not only include information about effective risk reduction behaviors, but also encourage both partners to keep abreast of their HIV statuses, including frequent testing and disclosure to partners.

For More Information

For a more in-depth discussion of these findings, refer to the full article, available in AIDS Education and Prevention. To read more about Dr. Beltrán’s work, check out her faculty page. 

Citation

Pearson, C. R., Walters, K. L., Simoni, J. M., Beltrán, R., & Nelson, K. M. (2013). A cautionary tale: Risk reduction strategies among urban American Indian/Alaska Native men who have sex with men. AIDS Education and Prevention, 25(1), 25-37.

References

¹ Fauci, A. S. (2010). Statement for National Native HIV/AIDS Awareness Day. Retrieved from http://www.ni-aid.nih.gov/news/newsreleases/2010/pages/nativehiv.aspx

² Cassels, S., Pearson, C. R., Walters, K., Simoni, J. M., & Morris, M. (2010). Sexual partner concurrency and sexual risk among gay, lesbian, bisexual, and transgender American Indian/Alaska Natives. Sexually Transmitted Diseases, 37(4), 7.

³ Catania, J., Osmond, D., Stall, R., Pollack, L., Paul, J., Blower, S., Binson, D., Canchola, J. A., Mills, T. C., Fisher, L., Choi, K. H., Porco, T., Turner, C., Blaire, J., Henne, J., Bye, L. L., & Coates, T. (2001). The continuing HIV epidemic among men who have sex with men. American Journal of Public Health, 91(6), 907-914.

⁴ Centers for Disease Control and Prevention. (2010). Prevalence and awareness of HIV infection among men who have sex with men—21 cities, United States, 2008. Morbidity and Mortality Weekly Report, 59(37), 1201-1227.

⁵ Centers for Disease Control and Prevention. (2012). Risk reduction chapter. In Divisions of HIV/AIDS Prevention (Ed.), Compendium of evidence-based HIV behavioral interventions: Updated April 5, 2011. http://www.cdc.gov/hiv/topics/research/prs/RRcomplete-list.htm: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

⁶ Chae, D. M., & Walters, K. M. (2009). Racial discrimination and racial identity attitudes in relation to self-rated health and physical pain and impairment among two-spirit American Indians/Alaska Natives. American Journal of Public Health, 99(Suppl. 1), S144-S151.

⁷ Lehavot, K., Walters, K. L., & Simoni, J. M. (2009). Abuse, mastery, and health among lesbian, bisexual, and two-spirit American Indian and Alaska Native women. Cultural Diversity & Ethnic Minority Psychology, 15(3), 275-284.

⁸ Nelson, K. M., Simoni, J. M., Pearson, C. R., & Walters, K. L. (2011). “I’ve ad unsafe sex so many times, why bother being safe now?”: The role of cognitions in sexual risk among American Indian/Alaska Native men who have sex with men. Annals of Behavioral Medicine, 42(3), 370-380.

⁹ Centers for Disease Control and Prevention. (2011). Serosorting among gay, bisexual and other men who have sex with men. Gay and Bisexual Men’s Health. http://www.cdc.gov/msmhealth/serosorting.htm: Centers for Disease Control and Prevention

¹⁰ Eaton, L. A., Kalichman, S. C., & Cherry, C. (2010). Sexual partner selection and HIV risk reduction among Black and White men who have sex with men. American Journal of Public Health, 100(3), 503-509.

¹¹ Zablotska, I. B., Imrie, J., Prestage, G., Crawford, J., Rawstorne, P., Grulich, A., Jin, F., & Kippax, S. (2009). Gay men’s current practice of HIV seroconcordant unprotected anal intercourse: Serosorting or seroguessing? AIDS Care, 21(4), 501-510.