During the past ten years, much attention has been given to the increasing number of adolescents migrating to the streets in every major urban area. Leaving home at a young age, few find legitimate means of financial support and many become victims of sexual exploitation. It is estimated that there are currently 600,000 female and 300,000 male adolescents involved in prostitution throughout the country.1
Traditionally, the term prostitute has been used in a female context, male prostitution being either ignored by or unknown to the general public. Recently, in-depth research has been conducted regarding factors influencing entrance into male prostitution.2'3 This work joins extensive research documenting early negative sexual experience, gender role conflict and limited employment opportunities as factors influencing involvement in prostitution.4
Physicians working in family and public health clinics in urban areas are in an advantageous position to provide intervention to male and female adolescents involved in prostitution. Medical personnel are often the only legitimate adult contacts these young people encounter over long periods of time. Physicians may frequently be able to identify children involved in street life and intervene in order to provide practical and supportive guidance.
This article will describe the process of involvement in prostitution, highlight characteristics of adolescent male and female prostitution, and offer practical suggestions for intervention by physicians with this population.
Reasons for entering prostitution are numerous. Economic factors play an important role and receive much attention in the general media. Few adolescents enter prostitution influenced solely by prospects of financial gain, however. Abusive childhood experiences often predispose and encourage adolescent prostitution. Most adolescent prostitutes are runaways. They leave home to escape a variety of circumstances including physical and sexual abuse, alcoholism, fighting parents and negative sexual labeling among peers.
Early negative sexual experience plays a significant role in entrance into juvenile prostitution.5 Experiences of rape, molestation and incest, common among young prostitutes, result in a lessened sense of sexual self-respect and of control over one's body. Adolescents are often not believed when they report sexual abuse. They are often blamed and internalize responsibility for their involvement. This results in further emotional trauma and negative self-labeling.6 Feeling different from their peers, they may begin to withdraw socially. Once sexually abused, the young person's ability to prevent further exploitation is eroded. In this manner, they are prepared for entrance into prostitution.5
Peer and group associations significantly influence entrance into prostitution. Many adolescents reach the streets with little or no knowledge of prostitution. After talking with peers who appear to be autonomous and making easy money, prostitution becomes a less frightening form of survival. They are often accompanied in their first prostitution activity by another individual involved in prostitution.2
For some, excitement is an important factor in entering prostitution. The "fast life" on the streets and in youth discos (where popular songs romanticize sex and prostitution), easy access to drugs, and having a variety of interesting companions involved in exciting and illicit activities all contribute to the appeal of street life. Involvement in prostitution also provides some with a sense of accomplishment and a source of attention. After a life of negative self-image and /or abuse, prostitution may provide an illusion of success.
Once adolescents are on the streets they are faced with the grim and unanticipated reality of few financial or social resources. They have few job skills or experiences. Many are even too young to obtain a work permit. They may be afraid of seeking legitimate employment for fear of being traced and arrested as a runaway, and being returned to a negative environment. For many, prostitution appears to provide the easiest means of survival.
Prostitution is damaging to adolescents in several ways. Most are neither emotionally nor sexually mature enough to endure the stress of street life without suffering significant psychological or physical damage. They are not aware of how involvement in prostitution can and will affect their life and future relationships. Adolescent prostitution lifestyles are very destructive. At a critical stage in personal development, these young people are not in school, have no legitimate employment, and do not have access to positive and non-exploitative adult role models. As a result, they fail to obtain the educational and employment skills necessary to succeed in the adult world. Their regular patterns revolve around working the streets at night. The associated daytime sleeping schedule and alcohol and drug use serve to further isolate and break down contacts the adolescent may have with the "real world."
Physical and sexual abuse are common in the lives of young people involved in prostitution. They are often afraid to report abuse from pimps, customers and others in the street subculture for fear of retaliation or arrest. Continued experiences with abuse reinforce feelings of helplessness and poor self-esteem. Contact with juvenile justice systems may amplify an already negative selfimage. Many develop serious juvenile criminal records.
Most of these young people do not understand how their life experiences ano! subsequent decisions have led them into prostitution. They are, however, aware of the societal stigma against prostitutes. Many prostitutes often internalize this stigma, blaming themselves for their circumstances. As a result, drug abuse and suicide ideation and attempt are common.
Although involved in numerous sexual encounters, most adolescents involved in prostitution are no more knowledgeable about sexuality than their non-street peers. Health problems are many. Pregnancy is often not recognized early nor cared for sufficiently; venereal disease is frequently undetected or left untreated.
The process of leaving prostitution can be long and arduous. Social support on the street, stigma and ostracism from their previous communities, financial need and lack of educational and employment experience all inhibit an adolescent's ability to break away from the streets. The longer a young person is involved in prostitution, the longer and more difficult her or his reentry into the "straight world" will be.
JUVENILE FEMALE PROSTITUTION
Young women who see prostitution as an acceptable option for themselves include those deprived and disadvantaged, those physically and sexually abused, and those affluent and over-indulged. Often these circumstances overlap in individual histories. The deprived and disadvantaged are generally from low social and economic status families. Prostitution is seen as the obvious route out of poverty. Often an adolescent's mother, aunt or sister has been involved in prostitution, serving as a role model and facilitating entrance into prostitution.
In a study of 138 juvenile females involved in prostitution,2 37% had been molested, 51% raped and 63% reported physical abuse. Sexual abuse tended to occur during childhood and included incest, molestation and rape. Prostitution offers the economic means necessary to remain independent of an abusive situation. Street companions provide friendship and understanding which were missing in homes or in legal placements.
The affluent adolescent involved in prostitution has succumbed to strong social pressures to be sexual and to measure self-worth in terms of money-making ability. Middle and upper-class girls admit to being overprotected, spoiled and very bored. The sensations from the illegality, immorality and danger of prostitution are a relief from the neutrality of their lives.3
A theory of sexual labeling provides a framework for understanding involvement in prostitution, male as well as female. Sexual labeling theory hypothesizes a relationship between negative sexual experiences during childhood and adolescence and a subsequently deviant lifestyle as an adult. Sexual experience with negative impact includes molestation, incest, rape, and early first intercourse with no subsequent relationship with sexual partner. Sexual self-concept is also affected by pregnancy, abortion, venereal disease and public knowledge about sexual activity.
Traditionally, women who have violated norms of sexual behavior have been evaluated as morally inferior.7 Even the child who is victimized by molestation may feel sexually spoiled, as does the rape victim who may be held responsible for provoking the assault.
A young woman may accept the norms of conventional behavior and recognize that her sexual experience precludes self definition as a "good girl." Once her sexual experience becomes public knowledge, loss of sexual status becomes formalized by peer and family rejection. Negative attributions and labeling may be locking a young woman into a deviant role. The sex role shift from the good girl to the bad girl may precipitate involvement in a delinquent sub-culture for social interactions, status and income.
Running away and involvement with thejuvenilejustice system provides exposure to prostitution and formal labeling as a delinquent. Each interaction with the legal system compounds the societal reaction to a younger woman's behavior by reinforcing labeling, negative attributions and sex typing as a deviant woman. She is further conditioned for increased sanctions and commitment to a deviant lifestyle.
The actual event which precipitates an act of prostitution varies. A young woman may barter for food, shelter or money. The majority begin prostituting on their own or with a girlfriend.2 The young woman often becomes involved with a pimp. The adolescent believes in the fantasy image offered by the pimp. The offer involves promise of financial and emotional support as well as increasing the girl's status as a "real woman." Involvement with a pimp is likely if a young girl continues to work on the street beyond a few weeks.
JUVENILE MALE PROSTITUTION
Deisher's 1969 study,8 states that male prostitution seemed to be a phenomenon of 16 to 23 year olds. Since that time, younger involvement in prostitution has increased at an alarming rate: in a similar study in the same city,9 it was easy to locate target males as young as 12 and 13 years old.
Juvenile males involved in prostitution can be divided into two groups: those who self-identify as heterosexual and those who self-identify as homosexual or bisexual. Previous research on male prostitution found the majority identifying themselves as heterosexual and bisexual/ Recent research indicates a major change: the majority of males involved in street prostitution now identify themselves as homosexual.9
There are some clear distinctions between heterosexual and homosexual prostitution groups. Those identifying as heterosexual are less willing to admit involvement in homosexual prostitution and usually have had little or no homosexual experience prior to entering prostitution. Their prostitution activity is less visible and is seldom a principal source of income. They prefer to survive by other criminal involvements such as robbery, burglary, drug selling, and pimping young females. During prostitution they are less inclined to follow through with sexual transactions and more likely to rob and assault their customers. They are uncomfortable with identification in a homosexual context, and frequently have fewer social contacts than their peers with a homosexual identity do.
Those identifying as homosexual are more likely to be on the street because of negative reactions from families and peers regarding sexual orientation. An adolescent teenager recognizing his homosexuality frequently wants more information regarding his feelings and may seek contact with other gay persons. He may discuss his sexual orientation with family members, school peers and authority figures within his community. Reactions to homosexual orientation are often characterized by rejection and persecution as opposed to acceptance and support. In addition, societal values have often viewed and labeled homosexuals as mentally ill, sinful and criminal. These messages are internalized by gay and bisexual youth and damage their images of self-worth.5 Openly gay adolescents face verbal harassment and potential physical violence from peers. Some are evicted from their family homes. Others, fearful of being exposed as homosexual, run away.
Adolescent homosexuals have little or no exposure to the diversity of the gay networks which exist in all urban areas. Once they are on the street, contacts with other persons identified as gay are largely limited to the street sub-culture. This social isolation results in a lack of positive representative homosexual role models, reinforcing negative messages of the homosexual as a sexual deviant. Damaged self-esteem; the desire to be with peers identified as gay, immediate financial needs and exposure to street life regularly lead to involvement in prostitution. Customers of juvenile males tend to be 30 to 50 years of age, mostly Caucasian and from a variety of social and occupational backgrounds.9 Male prostitution activity usually occurs in the customer's car or home. Going to the home of a customer seems unique to male prostitution; female prostitutes remain close to the street or in a hotel because of the danger inherent in isolation.
It is uncommon for male prostitutes to have pimps. There is some indication that the probability of involvement with a pimp increases for very young boys, especially in larger urban areas such as Los Angeles, Chicago and New York. Boys involved in prostitution understand the role pimps play in providing girls with protection and respect within the street sub-culture. Boys, however, tend to feel they do not need pimps. Sex-role conditioning, ongoing relationships with customers, and frequently, physical size combine to make males feel more capable of caring for themselves.
On the other hand, some adolescent males involved in prostitution have at least one "sugar daddy." A sugar daddy is a male customer with whom the boy develops an ongoing relationship. Young males usually favor a sugar daddy over regular street hustling for reasons including personal safety, financial security, the ability to spend less time on the street and lessening the psychological and physical demands of numerous anonymous sex partners. Over time, some develop a non-sexual friendship with the sugar daddy. They may still be provided with money and clothes. Some prostitutes prefer to survive without this type of relationship. They see such relationships as a threat to their independence; potentially too socially and sexually demanding.
Few males are arrested for prostitution activity; arrest statistics are much higher for juvenile female prostitutes.2 The usual way in which prostitutes are arrested is by propositioning or accepting an offer from an undercover officer. Male police officers tend to be uncomfortable posing as homosexual customers of male prostitution. By avoiding arrest, males involved in prostitution are spared the humiliation and public labeling that inevitably follow an arrest for prostitution. Unless they are arrested for other criminal involvement, they have fewer opportunities to contact medical and casework staff who may be helpful in realizing a departure from prostitution.
THE ROLE OF THE PHYSICIAN
Most female and male prostitutes receive medical care at the fringe of the health care system; they are usually seen in free clinics, emergency rooms and juvenile detention infirmaries. Street youth approach medical facilities and physicians with great hesitation. They perceive medical personnel as authority figures representing general societal values which conflict with their personal characteristics and experiences on the street. They will often not disclose lifestyle issues and medical concerns due to embarrassment, shame or fear of negative labeling. Hidden concerns are numerous and include involvement in prostitution, venereal disease, physical and sexual abuse, pregnancy, confusion around sexual orientation, homosexual relationships, drug abuse, depression and suicide ideation.
Juveniles involved in prostitution may also lack communication skills necessary to provide physicians with adequate information. Physicians should not expect an adolescent to fully present his or her concerns during an examination; many are not even aware of the medical problems they may have. Instead, examinations should be approached like an intake interview, with great care taken to gather information in an objective and nonjudgmental manner. Adolescents can perceive the slightest air of prejudice regarding their behaviors, resulting in the inhibition of open disclosure of vital information. Sexual histories and social network information are important in deciding upon proper medical and mental health intervention.
A major mistake in working with adolescents involved in prostitution is the assumption that sexual activity equates with an understanding of sexuality, venereal disease and birth control. This is rarely the case. Many have left home at young ages with only limited information provided to them at home or in school. Once on the street, access to further information is limited. Therefore, medical practitioners as well as staff of youth shelters and detention facilities should be sensitive to the health education of young people involved in prostitution.
Few juvenile females on the streets know about or have consistent access to reliable forms of birth control. Many do not use birth control on a regular basis. Similarly, male and female street youth know little about venereal disease. Adolescents are usually taught in school sex education programs only the more blatant aspects of venereal disease. They are not aware of the subtle forms such diseases can take, and therefore, will not seek medical exams unless they have more recognizable symptoms. Prior to reaching the streets they have been brought up with the same social values regarding sexuality representative of adolescents in general. Whereas unwanted pregnancy and exposure to venereal disease conflict with prior social self-images, they may deny vulnerability to these problems. Drug use and depression associated with street lifestyles will further distract them from this reality.
Developing rapport with gay and bisexual youth involved in prostitution may be far more difficult than with their heterosexual counterparts. Statements which may be perceived as biased or non-accepting should be avoided in the clinical interview. The use of non-gender specific pronouns such as "lover" or "sexual partner" instead of "boyfriend" or "girlfriend" are useful as are direct, non-judgmental questions regarding the patient's sexual orientation and practices. Although female prostitution is defined in a heterosexual context, physicians must not assume that all female prostitutes are heterosexual.
There is a startling lack of awareness among juvenile males of the variety of gay-related sexually transmitted diseases. There is considerable literature concerning the medical problems of homosexual male adults."'12 Heterosexual male prostitutes will be hesitant to disclose involvement in homosexual activity, especially with regard to anal intercourse. Young males involved in prostitution should be screened for gonorrhea and syphilis in the rectum as well as the throat and penis. They are also at risk for hepatitis of various sorts and unusual infections such as pneumocystis, giardiasis, amaebiasis, shigellosis, anal venereal warts, genital chlamydia and anal herpes. Traumatic injuries to the rectum should also be considered in the diagnosis of the male population.
Prescriptions for medications should be as simple as possible. Most street youth will not properly take daily dosages of medication, nor are they likely to return for follow-up examinations. It is often necessary to locate them for ongoing treatment. It is, therefore, important for the physician to obtain names of caseworkers, outreach workers and foster parents who are most likely to have continued contact with the adolescent.
Adolescents involved in prostitution are a mobile group. Many travel between cities in search of better prostitution markets, for adventure or to avoid arrest. Any contact with this group should be viewed as a unique opportunity for health education and intervention.
Medical personnel are in a unique and advantageous position to provide intervention with juveniles involved in prostitution. In order to work effectively with this population, it is important to understand childhood experiences which influenced involvement in prostitution, the dynamics of street life and barriers to providing proper health care.
Physicians should not assume that levels of sexual knowledge and sophistication are consistent with levels of sexual activity. Personal information must be gathered in an objective and non-judgmental manner. Attention should be given to shaping the adolescent's image of herself or himself as a sexual victim as opposed to a sexual offender.
Knowledge of the primary life issues of adolescents involved in prostitution (sexual abuse, street life, venereal disease, pregnancy, employment and educational opportunities, sexual orientation, drug abuse and depression) are essential and referrals for services may be necessary. Medical staff should be aware of local service and information resources for related topics and should be willing to act as advocates in securing such contacts.
1. Young A: Juvenile Prostitution: A Federal Strategy for Combating ils Causes and Consequences. Youth Development Bureau, Office of Human Development Services, US De p t of Health. Education, and Welfare, 1978.
2. James J: Entrance into Juvenile Female Prostitution: Final Report. Grant fl MH 29960, National Institute of Mental Health, August, 1 980.
3. Urban and Rural Systems Associates: Adolescent Male Prostitution: A Study of Sexual Exploitation, Etiological Factors and Runaway Behavior. US Dept of Health. Education, and Welfare, grant No. 105-79-1201. 1982.
4. Davis NJ: The prostitute: Developing a deviant identity, in Henslin J (ed): Studies in ike Sociology of Sex. New York, Appleton-Century-Crofts, 1971.
5. Boyer D: Easy money: Adolescent involvement in prostitution, in Da v id son S (ed): Justice for Young Women: Close-up on Critical Issues. Tucson, Arizona, New Directions for Young Women, 1982.
6. Burgess AW, Groth AN, Holstrom L, et al: Sexual Assault of Children and Adolescents. Lexington, Massachusetts, Lcxington Books, 1978.
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8. Deisher RW, Eisner V, Sulzsbacher Sl: The young male prostitute. Pediatrics 1969; 43:936-941.
9. James J: Entrance into Juvenile Male Prostitution: Final Report* Grant # M H 29968-05, National Institute of Mental Health, unpublished data. 1982.
10. Lebedeff D, H oc h man E: Rectal gonorrhea in men: Diagnosis and treatment. Ann Intern Med 1980; 92:463-466.
11. Own F: Sexually transmitted diseases and traumatic problems in homosexual men. Ann Infern Med 1980; 92:805-808.
12. Scnmerin M, Jones T, Klein H: Giardiasis: Association with homosexuality. Ann Intern Med 1978; 88:801-803.