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Sale of Sex for Drugs and Drugs for Sex: An Economic Context of Sexual Risk Behavior for STDs

Baseman, Janet MPH*; Ross, Michael PhD, MPH*; Williams, Mark PhD*†

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Abstract

SINCE THE BEGINNING of the crack epidemic in the 1980s, crack cocaine use has been associated with high-risk sexual behaviors such as inconsistent condom use and sex with multiple partners.1–5 Several studies have revealed that cocaine use is an independent risk factor for sexually transmitted disease (STD) infection, including HIV.6–10 In a recent study of crack cocaine users in Houston, TX, rates of STD infection were extremely high-11.3% tested positive for HIV, 14.9% for syphilis, and 53.3% for Hepatitis B.1

Crack use has become a serious public health threat in inner-city populations across the United States. Several studies of crack users have been conducted in various cities to define these populations in terms of culture, risk behavior, and disease status.

Attempts to define crack subculture have revealed that the exchange of sex for money or drugs is a common practice among many crack users.11–15 In a study of drug users residing in six southern U.S. cities, Elwood et al. found that crack users had a higher level of involvement in the trading of sex for drugs than other users and that black women were more likely to have reported a lifetime history of trading sex for drugs (42%) than white or Hispanic women (28% and 23%, respectively). Male crack users also reported having traded sex for drugs, although a smaller proportion of men had a history of this behavior.16

Drug-using commercial sex workers (CSWs), male and female, have been found to be at high risk for STD infection.15,17 In a study of Houston drug users who had used cocaine or an injected drug in the last 30 days, those who had a history of trading sex for money or drugs were found to have significantly higher rates of syphilis and HIV infection than those who had no history of trading sex for drugs.18

Most CSWs begin selling sex for financial reasons.19 They become CSWs to feed themselves and their families, or because they think they cannot make as much money doing legal jobs. CSWs who use crack should be no exception to such economic motivation leading to sex work, but the drug, rather than other financial needs, frequently motivates crack users to trade sex for drugs.20,21 The logistics and economics surrounding this drug-motivated type of prostitution are different from other types of prostitution, as an evaluation of the economic aspect of crack use and prostitution reveals.

Underground economies (such as markets for drugs or prostitution), despite their illegality, follow similar basic economic rules of supply and demand as legal economies. For example, the demand for a service such as sex, like the demand for many legal services, is elastic with regard to price and income.22 Thus, if the price of sex on the street increases, demand for sex services decreases. Likewise, if the price of such services decreases, demand increases. In terms of the income of the consumer of services such as sex, as the consumer's income increases, demand for services increases because consumers have more money to spend. As consumer income decreases, demand for such services decreases. This describes the fundamental laws of supply and demand.

Inelastic economies do not follow the same rules of supply and demand as do elastic economies such as the ones described earlier.22 The demand for crack appears to be inelastic with respect to price and income. Theoretically, if the price of crack increases, demand would not decrease as it would in an elastic economy because of the urgency involved in consumer demand for the drug. In terms of inelasticity of demand with regard to the income of the consumer (in this case, the consumer of the drug), if the income of the consumer of the drug decreases, demand for the drug would not decrease. As a result, the crack user would exhaust his or her financial resources to obtain the drug. Bear in mind that the demand for recreational drugs (such as marijuana) is considered elastic while the demand for more addictive drugs (such as crack) is frequently considered to be inelastic.

As the income of a recreational drug user decreases, or the price of the recreational drug increases, use of the drug declines. Conversely, as the addicted drug user's income decreases, or the price of the drug increases, use of the drug is maintained and personal financial resources are eventually depleted. Framing the demand for crack in economic terms allows for the contextualization of sex work and consumption of sex services within the crack market.

In such economic terms, the combination of desperation for drugs and sex work is dangerous on two fronts. First, longtime CSWs have complained that cocaine use has driven prostitution prices down.20,23 If crack-using CSWs drive the price of sex services down, often to the price of a drug fix, the demand for sex services increases because of the elasticity of the demand for sex services-sex is more affordable and, therefore, becomes more popular. Second, the consumer of the sex service has the upper hand in the transaction. With this upper hand, he (the customer is frequently male) can further lower the price or insist on dangerous sex acts in which the CSW normally may not participate (e.g., anal intercourse, unprotected sex).2,24 These trends, coupled with a high partner turnover rate, make for a dangerous sex market, increasing the likelihood of STD infection on several levels. The purchasers of the sex are as critical to maintenance of a dangerous market as are the prostitutes. While drug-using sellers of sex will generally come from a localized area where drugs are found, buyers of sex services have been found to come from within and outside the inner-city neighborhoods in which crack is bought and sold.11 This suggests that the repercussions of dangerous sex acts exist not only for members of communities in which drug use is rampant, but also for those who enter the scene for sex specifically, as well as for their other sex partners.

Researchers studying crack users16,23 and frequenters of gay bathhouses25 have posited the view of sex exchanges in terms of market-driven economics. These studies have indicated that economic forces, as well as hedonistic ones, seemed to propagate many of the sexual exchanges in the populations studied.

Crack use and high-risk sex have been implicated in the lack of containment of STDs in inner-city Houston.1,18 While other studies have established a connection among crack use, high-risk sex, and STD/HIV acquisition, none has attempted to identify the sex market players and quantify market involvement on a community level. The purpose of this article is to contextualize the Houston sex market and STD risk by describing the scope of, and interactions within, the underground economy for the trading of sex for money or drugs in two inner-city Houston zip code areas.

Methods

From January to March 1998, 818 street-intercept surveys were conducted in two inner-city Houston communities defined by zip code. The zip code areas are composed of predominantly black residents (approximately 95%) with median household incomes of $12,173 (77004) and $17,809 (77033). The two zip code areas were selected based on high prevalence of syphilis relative to other parts of the city.26 All respondents were older than 18 years and were residents of one of the targeted zip code areas. No compensation for participation was given.

Subjects were interviewed by one of two outreach workers, both practiced in interviewing in the target populations with the survey instrument used in this study. Subjects were approached in a variety of predetermined locations to ensure geographic distribution within, and site similarity between, the zip code areas. Such locations included fast-food restaurants, residences, bars, post offices, street corners, and housing projects. Most interviews were conducted during weekdays; however, interviews conducted in parks and bars were solicited after 5:00 pm during the workweek and on weekend evenings.

The survey contained 72 items and elicited information about sociodemographics, knowledge about syphilis, and sex and drug use behaviors. The study and survey instrument were approved by the University of Texas Health Science Center Committee for the Protection of Human Subjects, Houston, TX. Data were managed using Epi Info Version 6.0 (Centers for Disease Control and Prevention, Atlanta, GA). All data analyses were conducted using STATA Version 5.0 (Stata Corp., College Station, TX). Frequency measures, Cornfield odds ratios and 95% confidence limits, and Pearson chi-squared tests were used to determine frequency distributions and univariate relationships. Variables exhibiting a statistically significant univariate relationship to the dependent variables of interest were simultaneously added to a multivariate logistic regression model and were removed from the model in a backward step-wise fashion.

Results

The demographic characteristics of the study population of 818 persons are included in Table 1.

T1-5
TABLE 1:
Demographic Characteristics of the Sample of 818 Residents of Two High Prevalence Houston Communities, by Gender

Drug Use

A lifetime history of illicit drug use was reported by 81.5% of men (n = 379) and 76.5% of women (n = 267). Approximately two thirds of these men and half these women reported having used drugs in the last month. The illicit drugs of choice identified by study participants are displayed in Table 2. Among men and women, marijuana was the most frequently cited illicit drug of choice, followed by crack, and then cocaine. The least frequently cited drug of choice among men and women was heroin.

T2-5
TABLE 2:
Frequencies of Overall Drugs of Choice, and Drugs of Choice Among Those Who Had Used Drugs in the Last Month, by Gender

Sellers of Sex

A lifetime history of trading sex for money or drugs was reported by 21.5% of men. Men with a history of drug use were significantly more likely to have sold sex than men who reported they had never used drugs (OR = 2.09; CL 1.07-4.07). Table 3 displays odds ratios and 95% confidence limits for the relationship between drug preferences and a history of selling sex among men. Identification of crack, heroin, or cocaine as a drug of choice was significantly predictive of having sold sex among men. Men who reported having sold sex were significantly more likely to report having been tested for syphilis and HIV, more likely to report having had a new partner at their last sexual encounters, and less likely to report having used a condom at their last sexual encounters than men who had never sold sex (Table 3).

T3-5
TABLE 3:
Univariate Odds Ratios and 95% Confidence Intervals for Predictors of Selling and Buying Sex, Men

Approximately half the women sampled reported having traded sex for money or drugs. Women who reported having used drugs were significantly more likely to report having sold sex for money or drugs (OR = 15.45; 7.25-32.84). Reported drug use preferences for crack, cocaine, or primo (marijuana laced with cocaine) significantly predicted selling sex among women in univariate models (see Table 4). Women who reported having sold sex were significantly more likely to report having been tested for syphilis, having tested positive for syphilis, and having been tested for HIV. They were also more likely to report having had a new partner at their last sexual encounters than women who reported having never sold sex (Table 4).

T4-5
TABLE 4:
Univariate Odds Ratios and 95% Confidence Intervals for Predictors of Selling and Buying Sex, Women

Buyers of Sex

Among men in the sample, 58.4% reported they had bought sex with money or drugs. Men who had used drugs were more likely to report having bought sex with money or drugs than men who reported they had never used drugs (OR = 3.74; CL 2.28-6.14). Those drugs of choice that were significantly predictive of buying sex with money or drugs among men were speed, primo, cocaine, and heroin (see Table 3).

Men who reported having bought sex were significantly more likely to report having been tested for syphilis and having had syphilis at least once in their lifetime. Male buyers of sex were also more likely to report having had a new partner during their last sexual encounter than men who reported having never bought sex. There was no difference between male buyers and nonbuyers of sex in terms of condom use at their last sexual encounters (Table 3).

A lifetime history of buying sex with money or drugs was reported by 19.8% of women. These women were more likely to have reported having had syphilis, more likely to have reported ever having been tested for syphilis, and more likely to have reported ever having been tested for HIV than women who had never bought sex (see Table 4). Female buyers of sex were not significantly different from female nonbuyers of sex in terms of condom use and new partner at their last sexual encounters.

Income Distributions

Women who had sold sex brought in significantly less income, on average, than women who had never sold sex (χ2 = 10.00; P = 0.04). The income distributions of women who had bought sex were similar to those of women who had never bought sex.

Similarly, men who had sold sex were significantly poorer than men who had never sold sex, on average (χ2 = 11.78; P = 0.02). Men who had bought sex did not significantly differ on income from men who had never bought sex.

Multivariate Analyses

Among men, four variables were independently associated with a history of selling sex in a multivariate logistic regression model (Table 5): having had a new partner at the last sexual encounter (OR = 4.72; CL 2.75-8.09), indication of crack as a drug of choice (OR = 3.01; CL 1.70-5.34), having ever been tested for HIV (OR = 2.42; CL 1.25-4.70), and not having used a condom during the last sexual encounter (OR = 0.48; CL 0.27-0.86). Three variables were predictive of buying sex among men: indicating speed as a drug of choice (OR = 3.13; CL 1.33-7.36), indicating primo as a drug of choice (OR = 2.98; CL 1.19-7.47), and having had a new partner at the last sexual encounter (OR = 2.17; CL 1.33-3.55).

T5-5
TABLE 5:
Multivariate Odds Ratios and 95% Confidence Intervals for Predictors of Selling and Buying Sex

Among women, six variables were predictive of a history of selling sex after controlling for confounders in logistic regression analysis: not having a job (OR = 0.49; CL 0.27-0.89), having ever had syphilis (OR = 2.57; CL 1.16-5.71), having ever bought sex (OR = 3.60; CL 1.64-7.90), having had a new partner at the last sexual encounter (OR = 4.64; CL 1.92-11.23), indicating marijuana as a drug of choice (OR = 0.47; CL 0.24-0.95), and indicating crack as drug of choice (OR = 3.53; CL 1.86-6.70). Only two variables were independently predictive of a history of buying sex among women: having ever sold sex (OR = 3.97; CL 1.93-8.15) and indicating cough syrup as a drug of choice (OR = 3.66; CL 1.74-7.70). Cough syrup contains the chemical dextromethorphan (an opioid), but the significance of cough syrup as a recreational drug in Houston is unknown.

Discussion

The objective of this study was to describe the sex-drug market supporting high-risk sex practices in two inner-city Houston neighborhoods consistently registering high rates of STD infection. The proportions of men and women interviewed on the street who reported having participated in the sex market were disturbingly high: half the women reported a lifetime history of trading sex for money or drugs, as did one in five men; half the men reported a lifetime history of having bought sex with money or drugs, as did one in five women. Men who had ever used drugs were more likely to have a history of involvement in the sex market, which is not surprising considering that they would have the greatest access to a market currency (drugs) and the market commodity (cheap sex services.)

Because the sample was not randomly selected, our results are subject to several selection biases. A disproportionate number of surveys were conducted during daylight hours, which could overrepresent those who do not have daytime jobs, and furthermore, surveys conducted on the streets would overrepresent CSWs, because they are frequently hanging out on the streets. It should be noted that the survey questions assessing involvement in trading sex for money or drugs did not distinguish between those who had traded sex for money and those who had traded sex for drugs. Because knowledge of the frequency of each type of transaction could elucidate the role of each currency in supporting sex work in these communities, we have begun collecting data that differentiate between sex for money and sex for drugs transactions. Preliminary data suggest that both currencies (drugs and money) are well-established in the study population as a means of exchange for sex.

Selection of crack as a drug of choice predicted lifetime history of selling sex among men and women, supporting prior research to this effect and exemplifying the inelastic nature of demand for crack. The crack users turn to prostitution, which, owing to the omnipresence of sex work in crack-using populations, is an easy option (i.e., the market is already well-established in such communities).

An interesting phenomenon was observed in the data-after controlling for confounders, women who reported having ever sold sex were also significantly more likely to have reported ever having bought sex. This is inconsistent with the proposed economic model in that those who sell sex are not supposed to be able to afford to buy sex. One possible explanation for this trend is the existence of recreational sexual encounters in which drugs are used as a medium of exchange. The most recent data collected from a sample of 574 men and women from the same zip code areas in which the original survey was administered indicated that the sex market is supported by drugs and money, although money is the more frequent currency used in the transactions. Women who have bought sex appear to be equally likely to have used money and drugs to buy the sex, whereas money appears to be the more frequently used currency among female buyers of sex and male buyers and sellers of sex. Qualitative interviews with female crack users who have bought sex may clarify the underpinnings of this trend.

Although the inner workings of this underground sex market are poorly understood, the data are suggestive of a large and stable sex market with general trends mirroring what would be expected according to economic theory. In the two Houston communities studied, an economic sex market coexists with the crack market, with sex as the service in demand and drugs or money as the currency. The cycle of crack use and sex work appears to have a stable foundation in the laws of supply and demand. As more people are brought into the crack market, demand for crack increases, and more sex is sold (perhaps because of the desperation for the drug and the facility of access to the sex work infrastructure). The sex is already cheap (often set at the price of a drug fix, or a drug fix itself) so consumer demand for the sex is high. Introducing drugs as a currency lowers the price and thus, given that sex services are elastic, increases demand. Such increased demand may ensure that drugs become established as a stable underground currency in wide circulation. However, the drug user, as opposed to the CSW receiving money in the transaction, will have less power to insist on safer sex because of craving and a shortened time frame. In addition, drugs as a currency are less negotiable (in an economic sense) than cash. The result is a mass of unsafe sex exchanges and heightened risk of STD/HIV infection.

A more comprehensive community-based evaluation of the relationship between crack use and sex work could enhance the contextualization of the crack and sex markets within inner-city populations. As it stands, this study points to a critical mass of market-driven sex exchanges that could be a prime source of STD/HIV infection in poor, urban populations where crack use is common. The need to intervene in such populations is apparent. There appears to be three ways to make the critical mass of sex exchanges less critical, resulting in fewer STD transmissions. One way is to develop STD/HIV prevention messages targeting crack-using sex workers and the consumers of sex services. If this strategy were successful, it would make the critical mass of risky sex exchanges less critical by decreasing the number of high-risk sex acts, thus decreasing the number of STD transmissions. However, because the seller of sex has few choices in the sex transactions, it cannot be assumed that safer sex prevention campaigns would have any impact on these populations-such campaigns may need to be targeted to the buyers, who have the power to insist on condom use.27

Another way to decrease the frequency of such dangerous sex exchanges would be to target the crack problem directly. By decreasing the prevalence of crack use, fewer crack-addicted CSWs would exist, thereby diminishing the scope of the sex market. Even if the scope of the sex market did not diminish, but the number of crack-using CSWs did, the number of higher risk STD behaviors such as not using condoms may decrease. One possible way to target the problem on both fronts would be to initiate an increase in local drug treatment facilities and recruitment from the community to fill these spaces in such facilities. In this final scenario, STD/HIV risk education could take place within the framework of the drug treatment program, and crack use would decrease.

Regardless of the approach assumed, it would be beneficial to include such targeted interventions in an STD/HIV prevention plan to diminish the role crack has played in maintenance of such a costly and persistent public health problem. These data emphasize the critical importance of contextualizing sexual risk behavior before intervening. One such context is economic, and it is apparent that within this context, sexual behavior and drug use are part of a larger underground economy. Interventions in such a context will require targeting at a system and a behavioral, level.

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