Understanding the longitudinal relationship between substance use and violent victimization among street-based women who exchange sex in Baltimore, Maryland

Kristin E. Schneider, Catherine Tomko, Danielle Friedman Nestadt, Saba Rouhani, Rebecca Hamilton White, Michele R. Decker, Noya Galai, Susan G. Sherman

Research output: Contribution to journalArticlepeer-review


Background: Women who exchange sex (WES) experience extensive interpersonal violence from multiple perpetrators. Violence towards WES contributes to poor mental and behavioral health outcomes, including high rates of drug use. However, it is difficult to disentangle the temporal relationship between drug use and violence among WES. Methods: We used data from 251 WES, who completed baseline and 6-month follow up surveys. WES reported baseline sociodemographic characteristics, including homelessness and hunger. Participants reported their drug use by type and violent experiences by perpetrator at each time point. We conducted a path analysis examining the associations between drug use and violent victimization over time. Results: Participants were on average 37.8 years old, non-Hispanic White (57.4%) and experiencing high levels of structural vulnerability (59.4% homelessness; 58.6% weekly hunger). Drug use and violence were significantly correlated within each time point. Prospectively, baseline violent victimization was significantly associated with drug use (ß (SE) = 0.13 (0.06)) and violence (ß (SE) = 0.47 (0.05)) at follow up. Baseline drug use was associated with drug use at follow up (ß (SE) = 0.45 (0.05)) but was not significantly associated with violence at follow up (ß (SE) = 0.10 (0.06)). Conclusions: Violence and drug use are closely linked in this population; and violence appears to facilitate sustained drug use. Interventions to address the dual epidemics of violence and substance use in this population should address underlying trauma as well as socio-structural drivers of violence as well as tailored harm reduction services for this population.

Original languageEnglish
Article number103824
JournalInternational Journal of Drug Policy
StatePublished - Nov 2022

Bibliographical note

Funding Information:
The EMERALD Study was funded by the National Institute on Drug Abuse ( R01DA041243 ) and Johns Hopkins University Center for AIDS Research , a National Institutes of Health funded program ( P30AI094189 ). KES, SR, and CT were supported by a NIDA training grant ( 5T32DA007292 ).

Publisher Copyright:
© 2022


  • Drug use
  • Path analysis
  • Self-medication
  • Sex work
  • Violence
  • Women

ASJC Scopus subject areas

  • Medicine (miscellaneous)
  • Health Policy


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