Suicide and Prostitution among Street Youth: A Qualitative Analysis
Kidd, Sean A., Kral, Michael J., Adolescence
In recent years, increasing attention has been paid to the problem of street youth suicide in the research literature. Most studies report a suicide attempt rate for that population between 20% and 40% (Adlaf& Zdanowicz, 1999; Greene & Ringwalt, 1996; Molnar, Shade, Kral, Booth, & Watters, 1998; Rotheram-Borus, 1993; Stiffman, 1989; Yoder, 1999). Hwang (1999), in a study conducted in Toronto (Ontario death records 1995-1997), found that homeless males aged 18-24 had a completed suicide rate of 77/100,000. This rate is 10.3 times higher than the national rate for males of that age group. Of the possible explanations for these high rates of suicidal behavior, childhood physical and sexual abuse have received considerable attention. It has been found that street youth who have attempted suicide are more likely to have been physically and/or sexually abused than street youth who have not attempted suicide (Molnar et al., 1998; Yoder, 1999). Other factors that have been linked with suicidal behavior among street youth are being female, having a history of attempting suicide, being a "throwaway," poor self-esteem, depression, having a friend who attempted suicide, lack of food and shelter, fighting with peers, HIV/AIDS, a family history of substance abuse, and substance abuse (Greene & Ringwalt, 1996; Hagan & McCarthy, 1997; Ringwalt, Greene, & Robertson, 1998; Rotheram-Borus, 1993; Rotheram-Borus, Koopman, & Ehrhardt, 1991; Yoder, 1999).
A major stressor in the lives of street youth is finding a source of income. Research has indicated that 16-46% of street youth become involved in prostitution (Kipke, Unger, O'Connor, Palmer, & LaFrance, 1997; McCarthy & Hagan, 1992; Schissel, 1997; Yates, Mackenzie, Pennbridge, & Swofford, 1991), and the majority of those working as prostitutes are street youth (Farley & Barkan, 1998). When compared to other street youth, individuals who engage in prostitution more frequently report histories of childhood abuse, particularly sexual abuse (Adlaf & Zdanowicz, 1999; Schissel, 1997; Yates et al., 1991). Additionally, individuals who enter into prostitution as children/juveniles, especially those with histories of abuse, are more likely to have been forced into the sex trade (over 50%) (Larsen, 2000). The day-today experiences of persons who are prostituting themselves are equally bleak. Sexual and physical violence are common, they are an extremely high risk group for AIDS, and are frequently found to be suffe ring from posttraumatic stress disorder and depression (Earls & David, 1989; Farley & Barkan, 1998). Finally, street youth involved in prostitution have also been found to be more likely to be abusers of crack cocaine, and are more entrenched (heavily identify) with the street lifestyle (Adlaf & Zdanowicz, 1999).
Suicide among street youth working as prostitutes has received relatively little attention. Yates et al. (1991) found that these youth more often abuse drugs and are more likely to have made a suicide attempt. Seng (1989) found that children who engaged in prostitution were more "potentially suicidal" than children who had been sexually abused but had not been prostitutes. Adlaf and Zdanowicz (1999) did not find a significant difference in the suicide attempt rate for street youth invalved in prostitution. This was likely due to the very small number of such youth they used in their cluster analysis (n = 4), given that 3 of those 4 youth reported having made a suicide attempt. Such findings, in combination with high rates of recognized risk factors for suicide among this group, highlight the importance of further investigation.
A potential limitation of the research conducted thus far is that very little has been done to access the meanings street youth involved in prostitution give to their experiences. Investigating these meanings is important for determining the variables that might be involved and how these are situated culturally and contextually (Kazdin, 1998). Studying suicide by using narrowly operationalized variables may miss constructs important to the participants. This is especially likely given the differences in the experiences between street youth working as prostitutes and the mainstream populations from which many measures and much of current theory have been developed.
An influential interpretation of the phenomenon of suicide has been put forth by Shneidman (1996), who views suicide as an action taken when a person's threshold for psychological pain has been reached and becomes unbearable. This psychological pain arises from the individual's understanding of his or her past experiences, present circumstances, and potential future. Within this framework, an experience such as a history of sexual abuse is not a binary entry into a linear decision process of whether or not to end one's life. The emotional state of persons as they remember the abuse they suffered, and indeed the memory itself (Schacter, 1996), are strongly influenced by their personal understanding and perception of that experience and the context in which the act of remembering occurs. Further, this understanding changes as a function of context and cultural influence (Shore, 1996). It is from this theoretical stance that the present study was undertaken. The goal was to gain an understanding of what "suicid e" means to street youth who have been involved in prostitution-their understanding of the kinds of experiences and feelings that lead up to suicide, what a suicidal act is, and what happens after suicide. Also sought were the participants' perceptions of their strengths and the kinds of experiences that dissuade them from attempting to end their lives (an area too seldom addressed in suicide research). This inductive approach is contrasted with traditional deductive hypothesis testing in which the researcher's understandings of what comprises suicidal distress and risk are applied. It was hoped that the present study would reveal variables and constructs central to sex-trade-involved street youths' understandings of suicide.
Semi-structured interviews focusing on the topic of suicide were conducted with 10 females and 19 males ages 17-24 (mean age = 21.8 years). The criteria for participation were as follows: (1) All participants had to be 24 years of age or younger. This age was chosen as it reflects the age requirement for the social service where the interviews were conducted. (2) Participants must have left the home of their parents or legal guardian, either having run away or been thrown out, which resulted in a significant period of time in which they had no fixed address (i.e., more than a week). The participants were contacted and interviewed at a street outreach agency located in downtown Toronto. This agency offers counseling and a drop-in area for street youth, with a focus on helping youth involved in prostitution. In the agency, clients were directly approached by both the researcher and the staff, and asked if they wished to take part in the study. This method, in combination with a "pyramid effect" by which news o f the study spreads among street youth and their friends, was very effective in recruiting participants. A reimbursement of $10 in food coupons was given to each participant. Only one person refused to participate; participants were interested and cooperative.
Interviews and analysis were done by the first author. An attempt was made to engender a cooperative research relationship with a reduced power differential in the following ways: First, the goals and methods of the study were framed in terms of advocacy and the need to generate material that could help people working with street youth. Many street youth have had painful personal experiences with suicide and were motivated to offer their stories and understandings with a view to helping others in similar situations. Also, my position was negotiated mutually as a "go-between" with mainstream society. My role was to let people "out there" know the difficulties faced by street youth. Assuming this role was extremely important in facilitating the disclosure of participants who could have offered a bare minimum to receive compensation. In other words, they would likely have shared very little if the only purpose of the interview was research. An advocacy approach also helped gain access to street youth who might have never participated otherwise (e.g., youth who are extremely angry with members of mainstream society; youth who had a substantial income and for whom the compensation offered for the interview was inconsequential).
Second, the interview was conducted in such a manner that the participant was respected as a self-determining individual. In other words, privacy was respected and areas the person was reluctant to discuss were not aggressively pursued. The participants were not directly asked questions about sensitive or private topics such as abuse or suicide attempts. Rather, they were invited to speak of their experiences in an open-ended manner with the choice being theirs as to level of disclosure.
Interviews typically lasted between 45 minutes and one hour. Before inquiring about suicide, basic demographic information was obtained followed by general questions about their home and street experiences. At that point a series of open-ended questions were used to allow participants to describe their experiences with and understandings of suicide. The following are examples of interview questions: "If it is alright, we will talk about suicide now. You can tell me about a person you know who has committed suicide, and if you want you can tell me about your own experiences with suicide." "Has anyone you have known ever attempted or completed suicide? Can you tell me what happened?" "Do you think that having problems with boy/girlfriends might be related to suicide? How so?"
For this analysis the grounded theory coding procedure described by Glaser (1978) and Rennie, Phillips, and Quartaro (1988) was used. Although such a procedure was used, certain methodological differences preclude this study from being considered an example of grounded theory. The major difference was that I did not employ theoretical sampling (see Glaser, 1978, for a detailed description of grounded theory procedures). Stated differently, I have chosen a wellproven and methodologically sound approach to qualitative analysis (Rennie et al., 1988) and taken from it what best suits this study, as is often necessary in qualitative research (Denzin & Lincoln, 2000). This was the rigorous method of data analysis that is a part of grounded theory.
As the interviews were being conducted, I kept a notebook in which I wrote ideas, impressions, reactions-basically anything that came to mind related to the experience of talking with the participants. This procedure is called "memoing" or fieldnotes, and is an integral part of qualitative analysis (Rennie et al., 1988). It allows researchers to develop ideas about theory and the problem they are studying. Also, and of utmost importance, it provides a means by which researchers document their position in relation to the problem and the lives of the participants. Memoing continues throughout the analysis process.
After the interviews were transcribed, the analysis began by breaking the interviews down into "meaning units"--a few words, phrases or statements that convey a particular meaning. Since finding meaning is the goal of this study, units of meaning form the data rather than units based upon sentences. For example, one participant's comment that drug addiction was a process "like a toboggan slide off a cliff' was considered a meaning unit. In the coding procedure, similar meaning units are extracted and placed together to form categories. This process is referred to as "open coding" because a new category is created for each meaning unit that does not fit any previous category. For example, "incest" might be considered a category. As the categories are developed, they are constantly audited, merging categories that are redundant and breaking into separate categories meaning units within a single category that are better represented separately. The goal is to keep categories as distinct and mutually exclusive as possible while keeping the number of categories manageable and meaningful (i.e., not having hundreds of categories with only one or two meaning units in each category). During the process of open coding, the analysts keep careful memos documenting their developing ideas about how the categories relate to one another and how they might be arranged conceptually.
There is a movement from coding based primarily on interview content to theoretical coding, in order to determine how categories relate to one another conceptually. Hierarchies of categories are developed, patterns are found, their relationships explored and elucidated, and their conceptual "fit" sought. In theoretical coding, the categories themselves are arranged in an effort to develop a conceptual understanding, as opposed to content-focused coding in which the meaning units are clustered and arranged.
An internal verification process underlies the analysis. The categories and ideas about their relationships are continually brought back to the data for verification and further development. Some categories and ideas are dropped and/or subsumed into new categories as subsequent investigation of interviews results in a more thorough and better developed categorical framework. Furthermore, both theoretical and open coding are always tightly linked to the data with minimal interpretation by the researcher in an effort to reduce the influence of overt biases based upon the researcher's hypotheses.
As the researcher engages in this process of analysis, a category or small number of categories will usually begin to emerge that appear to be most central--core categories around which all others are arrayed and related. Development of core categories and how they are related to the phenomenon studied leads to the final stage of the analysis in which a theoretical model is developed that best fits the categories and their relationships. This step in the process was limited in the present study and forms the main reason why it would not be considered grounded theory. Development of the core category and its conceptual organization was limited since I did not incorporate this task as a part of the interviews.
A number of measures were taken to support validity both during and after the analysis. For a description of validity tests for qualitative research see Maxwell (1998). First, during the analysis, an effort was made to locate evidence that was discrepant or challenged the conclusions. This type of examination can call attention to areas where bias might have occurred and can also add depth to the analysis. Additionally, during the analysis, the amount of inference/interpretation was kept to a minimum by presenting the data close to the way in which the participants presented it. Second, after the initial analysis, an effort was made to obtain feedback from the original participants to determine if they thought the results of the analysis represented their understandings (10 of the original participants were located for this purpose). Third, the presentation of the data was detailed and complete, allowing the reader to directly view the evidence that supports the statements made. This involved providing many e xcerpts from the transcripts in the results and is known as "rich data." This strategy can serve to identify validity threats, biases, and flaws in the logic of the category developed (i.e., help establish trustworthiness) (Maxwell, 1998; Stiles, 1993). Fourth, "quasi-statistics" were used. This involved using descriptive statistics to illustrate how often a theme, category, or type of participant was present in the analysis. In addition, Fisher's exact test was used on several points of comparison (e.g., males compared with females). This test is appropriate for the analysis of qualitative data with small sample sizes (Hays, 1991). Finally, two research collaborators reviewed the original transcripts, coding, and category structure of six cases chosen at random. This technique of peer debriefing is recommended by Stiles (1993) as a method of offering the assurance that the interpretation has been found convincing by other investigators familiar with the source material.
The researcher worldview is that of a middle-class, white, heterosexual male. Conducting these interviews profoundly challenged many of my stereotypes. The participants trusted me and showed me some of their world with the understanding that this was a means through which their struggle might be heard. This led me to adopt the stance of an advocate along with the original goals of a researcher.
Throughout the body of the results, percentages are given which indicate the frequency with which various themes and categories arose in the narratives. While these numbers are helpful in forming a picture of the theme structure, their meaning in the context of this study must be made clear. As the interviews were not structured, these percentages only indicate how many people volunteered that piece of information. Thus, a percentage of 25% does not mean that the other 75% disagreed with this view or felt differently. What it does mean is that they did not mention it in their stories, which while very important, has a different set of implications than what is traditionally indicated with such statistical terms. The only information that was gathered in a structured format was demographic data.
Interviews were conducted with 10 females (mean age = 22.1, range = 20-24) and 19 males (mean age = 21.7, range = 17-24) who were primarily Caucasian (90%). Sixty-nine percent reported that they had been or were currently involved in prostitution (74% of the males and 60% of the females), though this is likely underreported as several chose not to disclose their sources of income. At least one suicide attempt was reported by 76% of the participants (73.6% of the males and 80% of the females), with most attempts involving either slashing of the wrists/arms or overdosing. Of those who reported attempting suicide, 86% reported making more than one attempt. Finally, 17% (11% of the males and 30% of the females) reported a history of self-mutilation, primarily cutting. Fisher's exact test revealed no significant differences between males and females on the variables described above. Generally, these individuals had "prostituted themselves," which refers to activities ranging from working out of escort agencies, t o working a "stroll" or street where tricks (customers) picked them up in cars, to trading sex for drugs. Most had a history of drug abuse and, depending on their level of income, lived in places ranging from the street, to hotel rooms, to their own rented apartments.
One Participant's Story
Before the results of the analysis are presented, which are necessarily fragmented in order to elucidate the categories and themes, one participant's larger narrative is presented. It is hoped this will give the reader a sense of the life narratives told by some of the participants.
Home was my dad molesting me and my mom on coke. And my dad leaving and my mom's boyfriends molesting me and my mom on coke. Same trip. I used to get beat a lot when I was a kid. I had a lot of suicidal tendencies, if that's what you're looking for. Home was rough. Home was poor. My mom was bringing tricks home and stuff and shit and fucking up big time. I don't know...it was pretty rough so I went to the streets and then I started prostituting. I was eleven and a half when I started selling myself. That was rough. I got raped a couple of times. I got stitches in my pussy, 37 of them to be exact, with a knife. I hung myself when I was thirteen...I hung myself three times in a year. I don't know ... the rest was just junk [heroin]. I used to do heroin and cocaine a lot, but I quit because I overdosed too many times.
Qualitative analysis was performed on 23 of the 29 interviews, as 6 of the interviews proved to be of insufficient depth to lend themselves to such analysis (i.e., consisting primarily of very brief answers). Those 6 interviews were used, however, in the compilation of information such as attempt rate, involvement in prostitution, and other demographics. The results are organized according to the chronological order in which they appeared in the narratives of most of the participants. For example, a category such as child abuse is presented before drug abuse which typically arose later in the narratives. Throughout the subcategories and categories certain recurrent/central themes were evident. These themes appear as central (i.e., pervade most categories) in the individual narratives with the following frequencies: Low Self-Worth (74%), Isolation (61%), Rejection/Betrayal (48%), and Lack of Control (30%). These terms arose repeatedly in the accounts of the participants and appear to represent emotional pain f or this group. The themes are presented within the contexts that they appeared and the domain areas discussed in the interviews. In other words, rather than presenting a theme such as isolation as a category, its role is highlighted in the presentation of "topic of discussion" categories such as child abuse.
Troubled/abusive family experience was a category in which the central themes appeared with the greatest frequency and intensity. Although not directly questioned in this area, 52% of participants described physical abuse and 44% described sexual abuse in their childhood. Experiences of rejection and betrayal appeared with great intensity in many of the participants' accounts of their lives before they came to the street (44%). The message of rejection and betrayal was perceived in abuse of all kinds, and often led to intense feelings of isolation (35%). This sense of isolation was especially prominent in the narratives of the gay and bisexual participants who revealed their sexual identity to family and friends and experienced rejection and isolation as something that they deserved for having such an identity.
[response to question regarding link between being gay/lesbian/bisexual and suicide]...some of us [gay persons] go through a lot of shit. Like me, my parents...my dad holding me up by my neck, three inches off the ground when he found out I was gay, saying why are you a fucking faggot. I didn't answer him and then he put a scar on my forehead, beat me to the ground, and then he packed a duffel bag, threw me out on the front step with blood all over me, shot twenty bucks at me and said, "go get yourself a life."
I walked out on Christmas and no one noticed.
[what led up to suicide attempts] I was just feeling abandoned because I was adopted, and then my parents kicked me out of the house after they adopted me and just issues like that, and I just felt worthless...
Closely related to experiences of physical and sexual abuse were the themes of low self-worth (39%) and a lack of control (26%). Most of these participants felt that the abuse and neglect that they suffered were the result of some failing in themselves. Lack of control arose from a combination of abuse and general family instability (e.g., multiple parent figures, deaths).
Getting beat up almost every day sometimes, and...you go through so many years of that, especially as a child, and you don't have any self-worth. Nobody has taught you you have self-worth. You are just taught that you are nothing and anything you do you deserve to be beaten, and you deserve to die.
...I really want to kill myself because I came from a really abusive home where my dad used to hit me, and my mother would do the same...and I had times when my mother would come into my room and tell me that I'm shit, and in my head I am shit, and everything around me is shit, and that is why I am falling apart...just hearing my mother tell me that I was a street rat and that I was worthless.
Most participants (68%) described their experiences with suicide attempts as beginning while they lived with a legal guardian, with 24% reporting that the only time they attempted suicide was before they came to the street. Of the seven who attempted suicide only before the street, five were gay and reported that the acceptance they found on the street among the gay community reduced their level of distress. The stories of abuse and neglect in childhood, filled with feelings of rejection, isolation, lack of control, and low self-worth, consistently formed a part of their narratives of their experiences with suicide/suicide attempts and understanding of what kinds of experiences resulted in self-destructive actions.
Prostitution. The themes of low self-worth and lack of control were strongly embedded in descriptions of experiences with prostitution. Percentages are not used here because only about one-third of the participants were comfortable with talking in detail about those experiences, thus percentages would likely have little meaning. Of those who did speak about such experiences, many described feelings of being merely an object for someone to "get off on" or "just some hole." Also, the feelings brought on by prostituting were linked with earlier experiences of sexual abuse: "That's what helped me become a prostitute, being abused."
A lot of the suicides come from the cheap prostitutes, because every time you do it, because I do it, every time you do it, it eats a piece of you up. You are sitting there going, some dirty old man wants me to have sex with him, and I don't want to do this, but I need the money, for this and that. Some kids think it is a big joke down there. It is not a big joke, a lot of people do really sick and nasty things to you. You feel so violated, that it eats you away slowly.
I'm a male prostitute...nothing but a piece of meat for someone to get off on, right?
In the participants' descriptions of the kinds of experiences that make up a really bad day, or preceded a suicide attempt, a "bad date" was described several times. Experiences which comprised a bad date were incidents such as not getting paid, a trick that takes too long or is too demanding, being beaten up, raped, or tricks who make offensive, demeaning comments. They described how these experiences brought back "all of the old feelings," feelings of anger and rage, and feelings of violation, with some of the participants saying that they had in the past tried to kill themselves immediately after a bad date. In this context the theme of loss of control was pivotal.
I used to be a male prostitute. I really wanted to commit suicide. It was bad; it was only like my second or third time, and I said no, and he [trick] locked both doors, both exits, he said yes. How can I say this...he was very large. That was the worst night of my life, after the heroin overdose of my girlfriend. I was afraid at the same time, because he was bigger than me too, so I had to stay. But he gave me seven bucks [sarcasm].
Drugs and money. Drug use and addiction appeared frequently in the participants' descriptions of the stresses in their lives and in the context of their experiences with, and understandings of, suicide. Drugs were spoken of as a way of forgetting the stresses of street life, forgetting the past, and in general "putting the pain aside" (44%). Another category that arose involved how some people on the street commit what was referred to as a "slow suicide" (22%). This was a phenomenon in which persons become more and more addicted to the drug, not caring about their lives and health, until they end up overdosing. Drugs were seen as being strongly related to suicide, either as a way of killing themselves (overdose), killing themselves while on the drug or when coming down, or killing themselves because of the addiction and the lifestyle of the addict. The central themes were not prevalent in this category since drug use was viewed as a reaction to those central themes.
It is the crashing, because after the high is gone, you have nothing. The high is gone, you are feeling depressed again, you can't afford any more drugs, you know, problems are back all over again.
I've known people who've had it hard on the street and have tried to kill themselves or killing themselves and prostituting themselves and doing crack and drinking too much. That's killing themselves slowly. And try to ease the pain; it may not be "oh, I'm going to slit my wrist" like I know some people have tried. That is like a slower burn, almost more painful. You just see them waste away. Completely waste away all the time.
Many participants (49%) in describing a "bad day," and the types of experiences that lead up to suicide, mentioned the stress of having little or no money. All other problems appeared to be worse when the person had no money with which to buy drugs, food, or lodging.
The only time I really think about it [suicide] is when everything seems to be caving in like, you know you are not making a lot of money pulling dates, you are pulling like three hundred dollars, four hundred dollars a week which is not a lot of money doing this.
Interpersonal factors. The participants, in their descriptions of friendships on the street, often spoke of the superficiality of the contacts made there, with only two participants mentioning being part of a "street family" or close and mutually supportive group of street youth. The central themes of rejection, betrayal, and isolation appeared in descriptions of friends, so-called, who were there when the person had money or drugs but ultimately did not care whether that person lived or died. In contrast, many spoke of having one or two close friends with whom they had been in contact for several years.
[led to a suicide attempt] Nobody cares about what happens to somebody that doesn't have money. Some people call themselves friends and say they are trying to help, but their version of help is using you to control you in some way. Drug dealers are always like, "oh, I'll help you get off the street." It's their way of making more money. And turning you into an addict at the same time because they will feed you tons of drugs in the beginning. [What did people do when you attempted suicide?] Nobody really gave a shit... the few people I told, they didn't care.
Most participants (70%) viewed problems with partners as a significant source of emotional pain and stress. All of the central themes of control, rejection/betrayal, self-worth, and especially that of isolation arose in this context. Many felt that intimate relationships were often more "intense" on the street, comprising the majority of that person's support network. The result of this "intensity" was that when there were arguments, abuse, or breakups, a lot of the "old issues" were brought up and in some cases were cited as reasons for a suicide attempt.
Yeah [suicide related to partner problems] because that person becomes your family, it's not totally just boyfriend/girlfriend sort of thing; you are looking for a little bit more sometimes.
...and also at the same time I tried it [suicide] my boyfriend at the time, he beat the shit out of me so I said, it's like "okay, I'm worthless," so I just tried ending it all.
Feelings. Respondents spoke of or were asked what kinds of feelings they were having when they made their suicide attempt(s). Those who had not made a suicide attempt described what feeling "really bad" was like for them. While most participants described having a mixture of feelings at such times, some categories arose from their descriptions. The feeling that dominated the reports was one of "aloneness," or "isolation" (56%). Other feelings that arose were of "depression" (37%), "emptiness" or "nothingness" (19%), and "anger" (13%).
All my attempts were done by myself. No one was there. So I am all alone. I am by myself, there is nothing there, no one cares.
[re: suicide attempts] A lot of times for me it was just being there and empty, and it is impossible to explain to someone who has never been there. They can't understand. When you have no money, no food, no home, no clothes, no possessions, that's when you feel empty.
Decision. Forty-nine percent of the participants identified a definite point when the above-mentioned feelings and negative, stressful experiences could not be tolerated any longer, and they turned to suicide as a way of ending the pain. Additionally, some of the participants analyzed their motivations at the time of their suicide attempts.
...all of a sudden it's just all there and you can't escape it...your past is there, your present is there, your hopeless future, it's all just in front of you. So at that point, how do I get rid of all these visions in my head, and want to just kill myself.
Sometimes I just think I deserve it [to die/suffer from attempt], and then sometimes...I feel guilty for being alive so I kind of try to solve other people's problems...and then sometimes I just want to put myself through a lot of shit so I do that because I know I am going to be in a lot of shit if I do that kind of thing. [Feel afterwards?] I feel like shit. Which feels good in away, so you know I got what I deserve kind of thing.
Reducing the Pain: What Helps
Thoughts. One thought that several participants (39%) reported as having helped them through bad times was that life was going to improve and that they will not always suffer as they do currently. This was related to self-worth, for though they might not value themselves now, there may come a time when they will be something "more." Other thoughts involved taking strength from their independence and self-reliance (30%), the valuing of oneself (30%), and the thought that they were not meant to die as a result of a suicide attempt after surviving so many (26%).
But then on the other hand I'm thinking to myself, well maybe I'll make it one day. Maybe I'll be famous for my art. Maybe I'll find a love of my life. Just maybe...when there is that maybe, why should I give up?
But the thing is, I tell people that I've tried suicide attempts so many times and it has failed. I've got to stop and think to myself: well, I have been put on this earth for one reason, and if I have tried to kill myself and it hasn't worked the first time, or the second time, or the third, fourth, or fifth time, I've got to be here until someone kills me or my time is up.
Actions. Most of the participants spoke of talking and spending time with friends as a way of coping with pain (61%). It appeared that while friendships were often perceived as superficial on the street, they still did form a part of the person's (already limited) support network. This action appeared to work against the theme of isolation. Other actions mentioned include sleeping (13%) and crying (9%).
... there is not much you can really do about it (emotional pain)... the best thing is to have people listen to you. Have people to talk with.
Outside sources of help. Very few participants (9%) reported having positive experiences with government-sponsored agencies or authorities. The only time any beneficial assistance was described, it involved street outreach agencies or shelters. They reported positive experiences as utilizing a nonjudgmental approach, with people who listen, and places where they were assured of confidentiality. Many narratives (48%) described negative experiences with agencies and mental health professionals. The central theme of lack of control arose most pervasively in this context; the majority of the reports involved being "locked up" in hospitals, staffed by cold, uncaring professionals who did little but prescribe drugs.
... as opposed to a shrink telling me, "oh, it's just a part of your borderline symptoms." Great. "Part of my borderline symptoms" says if that doesn't cure my problems you are going to give me more drugs. Great, yeah, give me more lithium so I can get totally wrecked now.
In the present study a qualitative analysis was performed on the narratives of street youth interviewed at an outreach agency in Toronto. The focus of these semi-structured interviews was on suicide and suicidal behavior. The findings were that, for this group, emotional pain was composed of experiences with and feelings of isolation, rejection/betrayal, lack of control, and most pervasively, low self-worth. The participants viewed the origins of their emotional distress in their abusive and neglectful upbringings. These painful experiences at home led to a life on the street, where extremely negative experiences continued, maintaining and in some instances exacerbating this painful self-image of worthlessness. These powerful negative feelings, combined with few options for reducing the pain either due to external factors or internal perceptions, all within an understanding of self-harming/destructive behaviors as a way of reducing pain, appear to lead to an extremely high rate of suicidality.
The incidence of physical/sexual abuse was difficult to assess with this group, as they were not directly questioned on this topic. This point aside, the number of participants who freely described their abusive pasts was consistent with the incidence rates of abuse reported previously (Molnar et al., 1998; Yates et al., 1991). Additionally, the present study supports the street youth literature that suggests that a history of abuse is related to suicidality (Molnar et al. 1998; Schissel, 1997; Yoder, 1999) and prostitution (Yates et al., 1991). This finding is of note because it is the participants who are making this connection rather than having it inferred from correlations between histories of abuse, suicidality, and prostitution. What appears to be absent in the literature is an attempt to discern the meaning street youth give their abusive experiences in terms of their past and current psychological functioning and its relationship to suicidal behavior. The themes that arose from the narratives of the present study in the context of abuse and suicide were feelings of rejection, isolation, low self-worth, and lack of control. These themes represent the participants' experiences of their abusive pasts and their perceptions of a painful experience that necessitated a suicidal action to reduce the pain. As such, interpretations of past abuse involving these themes may indicate a person at risk for suicide among a similar population.
Participants in the present study differ from those commonly found in other studies of street youth in that they are older, and composed mainly of individuals reporting involvement in prostitution. These differences are noteworthy given the present study's finding of a suicide attempt rate of 76%, roughly twice that typically found among the street youth population (e.g., Molnar et al., 1998). Along with demographic considerations, it may also be possible that the semi-structured nature of the qualitative interview facilitated greater disclosure. Of these potential explanations for the high suicide attempt rate reported, involvement in prostitution would appear to be the most salient, given that it has been linked with suicidality among street youth (Yates et al., 1991) and is extremely destructive to both physical and mental health (Farley & Barkan, 1998). The present study expands upon previous findings, noting that for these participants, the elements of prostitution that they felt led to suicide were low self-worth and a loss of control. Also, and described as extremely traumatic by the participants, was the experience of having a "bad date" which means being assaulted during prostituted sex. Exposure to this type of violence was linked to suicidal behavior.
The finding that drug abuse is related to suicidal behavior both as a coping mechanism and a means of suicide supports previous work (Molnar et at, 1998; Rotheram-Borus, 1993). Drug abuse as "slow suicide" may be similar to high-risk behaviors which have been observed at high levels among street youth (Ringwalt et al., 1998), and recent research points to a suicidal element in drug abuse and frequent overdoses (Neale, 2000). The present study's finding that lack of money is related to suicide is found in previous studies, where the stress of poverty has been linked with increased distress, depression, and suicidality (Hagan & McCarthy, 1997). A unique finding of the present study is that a day without food and shelter was often described as the breaking point for the participants, leading to suicidal behavior.
The potentially negative impact of "friends" on the street, a category that arose in this study, has recently been examined by Whitbeck, Hoyt, and Bao (2000). Whitbeck et al. (2000) spoke of how the strong need to quickly form friendships on the street leads street youth into relationships in which they are often coerced and manipulated by street "predators." Even when they are not actively used/manipulated, their association with peers engaged in destructive coping strategies (e.g., drug abuse) leads newcomers to adopt similar behaviors. The somewhat contradictory finding that friends were also spoken of as important for coping has also been noted previously. In the street youth literature, having friends has been inversely correlated with depression (Smart & Walsh, 1993). The importance of partners in the lives of street youth and the distress and suicidality surrounding problems with these relationships have received little attention in the literature.
The central theme of isolation has been observed previously among street youth (McCarthy & Hagan, 1992), with the theme of rejection more often described as an experience (I was rejected) rather than a feeling (I felt rejected) (Savin-Williams, 1994). Neither of these themes has been linked with suicide in this group before. Nor has the central theme of lack of control been found in any previous study on street youth suicide. The most common central theme, low self-worth, is found in the general street youth literature (Hagan & McCarthy, 1997) and has been found to be a risk factor for suicidaility (Yoder, 1999). However, its centrality in the construct of suicide has not previously been highlighted. It is difficult to say if the thematic/variable differences described above are due to the inductive methodology employed or are specific to street youth involved in prostitution.
In conclusion, suicidal thoughts and behaviors among these sex-trade-involved street youth appear to be very strongly tied to low self-worth and feelings of isolation, rejection, and lack of control. These are the elements of psychic pain for this population that are linked to suicidality, and need to be addressed by persons working with street youth, by those involved in the design of primary prevention efforts with youth, and by researchers looking closely at the nature of suicide among street youth.
The findings of this study have highlighted the importance of assessing street youth involved in prostitution for strong feelings of worthlessness and lack of control in their descriptions of how prostitution is impacting their lives, and monitoring the outcomes of occurrences such as assault during prostituted sex. There are a few key areas in which suicide intervention/prevention efforts would likely be most useful. A nonjudgmental stance, very important in any such work, is vital when working with street youth. Suicidal street youth often feel worthless as they think about their identity as a drug addict, prostitute or street rat. In such a context, talking to someone who is not judging them can be very powerful. Helping persons find some ability or talent can also be very important in their development of a sense of worth. There is an enormous and largely untapped potential residing in these youth, and helping them find it is a key part of the healing process. Emphasizing their strength at having survive d, and the knowledge they have gained through their survival, helps build a sense of control and agency. This can work against the "lack of control" feeling that many associate with suicide. Helping them develop a support system of people who care for them without wanting money, sex or drugs in return will be a part of any such work. This will likely be most effective if it extends beyond mental health workers, who could be perceived as "just doing their job." Addiction work may also play a major role.
The present study had two primary limitations. First, further work must be done to determine if the present findings are applicable to other subgroups of street youth. Second, while the present study had considerable breadth and generated several variables and associations not previously addressed, a more focused and controlled examination of these variables is called for in future studies. While a weakness, this was also this study's strength, as it highlights the utility of inductive, exploratory research in finding new avenues of investigation and in guarding against the researcher's choice of measures that may limit the findings (especially with cultures/subcultures different from previously researched populations). Also, it demonstrates the importance of looking beyond simplistic, linear, risk-factor models to the subjective experiences and contexts of the participants, and the influence these have on their decision to attempt suicide.
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This study was supported through an Ontario Graduate Scholarship grant. The authors gratefully acknowledge the assistance of Susan Miner and the staff of Street Outreach Services as well as Eleanor MacKenzie for her comments on earlier drafts of this paper.
Michael J. Kral, Department of Psychology, University of Windsor, Ontario, Canada.
Reprint requests to Sean A. Kidd, Department of Psychology, University of Windsor, 401 Sunset, Windsor, Ontario, Canada N9B 3P4.…
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Publication information: Article title: Suicide and Prostitution among Street Youth: A Qualitative Analysis. Contributors: Kidd, Sean A. - Author, Kral, Michael J. - Author. Journal title: Adolescence. Volume: 37. Issue: 146 Publication date: Summer 2002. Page number: 411+. © 1999 Libra Publishers, Inc. COPYRIGHT 2002 Gale Group.
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