Exploring the contextual factors and decision-making process of risky sexual behavior among homeless adults in Louisville, Kentucky.

Abstract

Homelessness is a complex public health issue; individuals who experience homelessness are said to engage in risky sexual behaviors at an increased rate and experience a higher prevalence of sexually transmitted infection (STI). While the sexual behaviors of homeless adolescents are commonly studied, little is known about the sexual behaviors of the growing population of older adults, or how they make decisions to engage in sex. Three aims guided this research: 1) to describe the sexual behaviors and sexual decision-making process of homeless older adults, 2) to examine how homeless older adults evaluate the outcomes associated with engaging in risky sexual behaviors, and 3) to identify the predictors of sexual behaviors in which homeless older adults engage. This study used a qualitative approach, which included five key informant interviews with providers of homeless services and twenty interviews with the target population. A purposive sampling method was employed by utilizing an indirect facilitation approach, relying on a partnership with local service providers to identify and refer individuals who they believed met the eligibility criteria. Results of the study reflect that while homelessness presents barriers to healthy relationships, older adults experiencing homelessness engage in sex for personal benefits, including the ability to meet their basic needs through transactional opportunities and the need for interpersonal connection. As noted in other studies on homelessness, living in shelters and on the streets presents inherent risks to physical and emotional safety, with increased risk of vulnerability and victimization. Homeless individuals identify STIs/HIV and physical harm as results of sexual encounters, and although these risks can be mitigated, they do not motivate individuals to apply discretion and safer sex practices. In fact, participants expressed confidence in their ability to use safer sex practices and noted the accessibility of condoms, yet did not perceive themselves to be at risk at the time of the sexual encounter. One primary barrier to implementing safer sex practices while experiencing homelessness is the use of substances. The population experiences negative interpersonal relationships, with reports of social disconnection and unfavorable influences of substances on relationships.