The social logic of sexual risk-taking among homeless young people in Pakistan

Internationally, the relationship between homelessness and the increased risk of sexual transmission of HIV is well established. However, little is known about the social processes that shape homeless young people’s sexual choices, decisions, and practices in the context of Pakistan. To address this gap, semistructured interviews were conducted with twenty-nine homeless young people (aged 16-25 years old) from Rawalpindi, Pakistan, including nine cisgender heterosexual men, six cisgender heterosexual women, seven cisgender gay men, and seven transgender heterosexual women. Bourdieu's concepts of capital and social practice guided the analysis of interview data. The analysis revealed that participants’ pathways to homelessness were shaped by the decline of their families as a source of social capital including the poverty of the family, the stigma of being transgender or gay, and through experiences of domestic violence and illicit drug use. Once on the streets, participants improvised with the limited resources available to them by drawing on and reciprocating peer support, pursuing casual work and engaging in dance and/or sex work to accumulate needed resources. While sex helped some participants secure physical protection, social and emotional support and money, it carried risks of HIV/STI, violence, degradation, and social marginalisation. Participants were aware of their sexual health risks, but the social obligations of intimate partnerships, financial considerations, and fear of violence from clients collectively produced a context of competing risks, where protection from HIV/STI became secondary to maintaining relationships, income generation, and physical safety. Also, in relation to sex, participants adopted alternative strategies to protect themselves from HIV, including practices like only performing oral sex, post-sex anal douching, using the withdrawal method and adopting specific sexual positions when not using condoms. Nevertheless, these strategies were not always protective and sometimes inadvertently increased their risk of HIV/STI. The study’s identification of structural and contextual forces that shaped young people’s trajectories into street life, as well as their sexual risk-taking, have implications for policy and programs. An integrated health promotion approach that goes beyond the health sector may help to reduce young people's risk of homelessness and HIV/STI in Pakistan. Building healthy public policies, creating supportive environments, strengthening community actions, developing personal skills, and reorienting health services could help to improve young people’s socioeconomic status, which affects their capacity to practise safe sex and relationships.