Steven P. Kurtz

Barriers to Health and Social Services for Street-Based Sex Workers

Homelessness, poverty, drug abuse and violent victimization faced by street-based women sex workers create needs for a variety of health and social services, yet simultaneously serve as barriers to accessing these very services. The present study utilized interview (n = 586) and focus group (n = 25) data to examine the service needs and associated barriers to access among women sex workers in Miami, Florida. Women most often reported acute service needs for shelter, fresh water, transportation, crisis intervention, and drug detoxification, as well as long-term needs for mental and physical health care, drug treatment, and legal and employment services. Barriers included both structural (e.g., program target population, travel costs, office hours, and social stigma) and individual (e.g., drug use, mental stability, and fear) factors. Bridging these gaps is tremendously important from a public health perspective given the disease burden among this population. Recommendations include service staff training, outreach, and promising research directions.

Sex Work and Drug Use in a Subculture of Violence

This article examines the subculture of violence thesis as it relates to female street sex workers in Miami. Interview and focus group methods were used to study the intersections of childhood trauma, drug use, and violent victimization among 325 women. Using targeted sampling, crack- and heroin-using sex workers were recruited through street outreach into an HIV-prevention research program. Interviews used standard instrumentation and focused on drug-related and sexual risk for HIV, sex work, violence, childhood trauma, and health status. Nearly half of the respondents reported physical (44.9%) and/ or sexual (50.5%) abuse as children, and over 40% experienced violence from clients in the prior year: 24.9% were beaten, 12.9% were raped, and 13.8% were threatened with weapons. Consistent relationships between historical and current victimization suggest that female sex workers experience a continuing cycle of violence throughout their lives. The policy and research implications of these findings are discussed.

Post-Circuit Blues: Motivations and Consequences of Crystal Meth Use Among Gay Men in Miami

Miami, Florida was at the vanguard of the rise of circuit parties and attendant club drug use—especially ecstasy, GHB, and ketamine—in the 1990s. Crystal methamphetamine, a drug of abuse among gay men for some years on the West coast, gradually moved east toward the end of the decade and recently became prevalent in Miami. This paper reports the results of focus group research into the motivations and consequences of crystal use among gay men in this new setting. Loneliness, fears about physical attractiveness due to aging and illness, and desires to lose sexual inhibitions were common motivations for using the drug. Continued use of crystal was often described as the cause of lost friendships, employment and long-term relationships, as well as sexual behaviors that put men at risk for HIV and other sexually transmitted infections. Implications for drug and sexual risk prevention interventions are discussed.

Migration, neighborhoods, and networks: approaches to understanding how urban environmental conditions affect syndemic adverse health outcomes among gay, bisexual and other men who have sex with men.

Adopting socioecological, intersectionality, and lifecourse theoretical frameworks may enhance our understanding of the production of syndemic adverse health outcomes among gay, bisexual and other men who have sex with men (MSM). From this perspective, we present preliminary data from three related studies that suggest ways in which social contexts may influence the health of MSM. The first study, using cross-sectional data, looked at migration of MSM to the gay resort area of South Florida, and found that amount of time lived in the area was associated with risk behaviors and HIV infection. The second study, using qualitative interviews, observed complex interactions between neighborhood-level social environments and individual-level racial and sexual identity among MSM in New York City. The third study, using egocentric network analysis with a sample of African American MSM in Baltimore, found that sexual partners were more likely to be found through face-to-face means than the Internet. They also observed that those who co-resided with a sex partner had larger networks of people to depend on for social and financial support, but had the same size sexual networks as those who did not live with a partner. Overall, these findings suggest the need for further investigation into the role of macro-level social forces on the emotional, behavioral, and physical health of urban MSM.

Sex Work and “Date” Violence

This study employed survey and focus group methods to examine the characteristics and sex work-related behaviors of 294 female street-based sex workers in Miami that make them more likely to be victimized by their clients or “dates.” More than half the respondents had experienced date violence in the prior year. Economic desperation, using crack or heroin while working, not controlling the date location, and having sex in the car were strong predictors of victimization. The article concludes with recommendations for a harm-reduction approach to outreach and education, and it calls for increased legal protections for victimized sex workers.

The “Black Box” of Prescription Drug Diversion

ABSTRACT A variety of surveys and studies are examined in an effort to better understand the scope of prescription drug diversion and to determine whether there are consistent patterns of diversion among various populations of prescription drug abusers. Data are drawn from the RADARS System, the National Survey of Drug Use and Health, the Delaware School Survey, and a series of quantitative and qualitative studies conducted in Miami, Florida. The data suggest that the major sources of diversion include drug dealers, friends and relatives, smugglers, pain patients, and the elderly, but these vary by the population being targeted. In all of the studies examined, the use of the Internet as a source for prescription drugs is insignificant. Little is known about where drug dealers are obtaining their supplies, and as such, prescription drug diversion is a “black box” requiring concentrated, systematic study.

The diversion of prescription drugs by health care workers in Cincinnati, Ohio

Data are reported from drug diversion cases involving health care workers who were investigated by the Cincinnati Police Division Pharmaceutical Diversion Squad over an 11-year period. This type of information is rarely available because few U.S. police jurisdictions dedicate resources to prescription drug diversion surveillance. Data from 1992 through 2002 show that opioids were the drugs most commonly diverted by health care workers, followed by benzodiazepines. Nurses, nursing assistants, and medical assistants were involved in almost three quarters of all cases. Hospitals were the most common sources of complaint to police, followed by pharmacies. Health care professional associations are advised to promote greater awareness of drug misuse and dependence concerns among their memberships, and health care facilities that stock pharmaceuticals liable for misuse and diversion are advised to increase the security of their supplies.

Resilience, Syndemic Factors, and Serosorting Behaviors Among HIV-Positive and HIV-Negative Substance-Using MSM

Serosorting is commonly employed by MSM to reduce HIV risk. We hypothesize that MSM perceive serosorting to be effective, and that serosorting is predicted by resilience and inversely related to syndemic characteristics. Surveys included 504 substance-using MSM. Logistic regression models examined syndemic and resilience predictors of serosorting, separately by serostatus. For HIV-positive men, positive coping behaviors (P = .015) and coping self-efficacy (P = .014) predicted higher odds, and cognitive escape behaviors (P = .003) lower odds, of serosorting. For HIV-negative men, social engagement (P = .03) and coping self-efficacy (P = .01) predicted higher odds, and severe mental distress (P = .001), victimization history (P = .007) and cognitive escape behaviors (P = .006) lower odds, of serosorting. HIV-negative serosorters reported lower perceptions of risk for infection than non-serosorters (P < .000). Although high risk HIV-negative men may perceive serosorting to be effective, their high rates of UAI and partner change render this an ineffective risk reduction approach. Relevant public health messages are urgently needed.

Reductions in prescription opioid diversion following recent legislative interventions in Florida.

Florida has been at the center of the nations ongoing prescription opioid epidemic, with largely unregulated pain clinics and lax prescribing oversight cited as significant contributors to the opioid problem in the state.

The Connections of Mental Health Problems, Violent Life Experiences, and the Social Milieu of the “Stroll” with the HIV Risk Behaviors of Female Street Sex Workers

Abstract This paper examines the connections of mental health, victimization, and sexual risk behaviors among a sample of 278 street-based female sex workers in Miami. Using targeted sampling strategies, drug-using sex workers were recruited into an HIV prevention research program. Data were collected by trained interviewers, and focused on drug use and sexual risk for HIV, childhood abuse, recent victimization, and mental health. More than half of the participants reported histories of physical (51.1%) or sexual (53.1%) abuse as children, 37.4% were classified with moderate or severe anxiety symptoms, and 52.9% had symptoms of moderate or severe depression. Logistic regression analyses demonstrated significant associations between mental health issues and engagement in recent unprotected vaginal and oral sex. The program development and policy implications of these findings are discussed.