The Adolescent Alone
Getting Off the Streets

Neither the process of protecting oneself on the streets, nor of leaving street life itself, is as simple as making the decision to do so. The economic, social, and emotional forces that keep youth on the streets include a lack of jobs and housing, and insufficient education and social support. Many youth come to the streets with mental health problems (Canton 1986). Once on the streets, moreover, many develop coping patterns that serve to reinforce the structural barriers they encounter in trying to change.

A nineteen-year-old Hispanic youth, involved in prostitution, contends that his drug use prevents him from getting off the streets. This youth explained that the only way out is to leave New York City altogether:

But I'd have to go away! That would be my best thing, to go away to a long-term residential drug treatment program and get it together. The way I support myself, it's tough.

Street youth have particular needs regarding drug treatment that often are not addressed in traditional programs. For the large number of drug-involved street youth who are gay, lesbian, or bisexual, drug treatment is especially problematic in general and the relationship between, sex and drugs among street youth in particular. Moreover, after some time on the streets, drug use becomes an integral part of many street youths' lives, often playing an adaptive role; conventional forms of treatment that hold abstinence as their goal are seldom realistic approaches if they fail to consider the void that drug use sought to fill in the first place.

For youth who find other avenues closed to them, and who feel a lack of support, the street economy itself can be addictive. The situation for most street youth is a vicious circle. They need a place to live in order to look for, and hold, a job; they need a job in offer to afford a room or apartment. A nineteen-year-old African American youth explained:

A stable place to stay would be the best thing [for me]. If I had a stable place to stay, I could go in and out to work, you know, and it would be alright....I mean, if I had a place to stay, I could get my own food, and I could support myself. But, you know, not a shelter system.

Subsisting on $215 a month in public assistance and occasional earnings from prostitution , a twenty-two-year-old black youth said that the only people he knew who had been able to acquire hosing were those whose illness with AIDS entitled them to subsidized housing. It occurred to him that if he contracted HIV it would solve his housing problem but decided that it was not worth the new set of problems he would face.

The multiple difficulties in the lives of street youth are compounded by the barrier they encounter in trying to obtain services. A twenty-three-year-old white youth described his feelings about being homeless, mentally ill. and addicted to drugs.

This youth had spent his early childhood and adolescence moving from one foster home to another and had endured physical and sexual abuse at the hands of foster parents. He ran away from the foster care system at the age of seventeen and began living in the streets. There, he took up hustling, drug dealing, robbing, and stealing in order to survive. On his own, he sought admission to a program for mentally ill chemical abusers, but he was not accepted. He explained the futility of his efforts:

And then they want to know why I got to hustle and sell crack and do all that blush, and meanwhile I'm always getting arrested. They want to know why. And then they want to know why it's our fault because we're out here. It's not our fault. Maybe it's our parents' fault sometimes. It's not always us. We didn't pick the choice to be out on the street. And now it's too late. Now I can't do nothing. Everything people walk past me they look at me like I'm some kind of slouch. That makes me look bad. I feel hurt....I feel left out.

DISCUSSION
As reflected in their life stories, many of these youth come to the streets having already been exposed to profound emotional trauma, experiences that are exacerbated by the violence and exploitation that characterize everyday life on the streets. However, the mainstream service delivery system is often ill-equipped to meet the needs of this particular population of youth. Drug treatment resources, for example, are very limited. Prevailing treatment modalities have little efficacy and may do more harm than good. They are not equipped to deal with the clinical issues these youth confront, and absence of attention to these issues often results in youth leaving services prematurely and increases their sense of failure. Similarly, gay and lesbian street youth have a wide range of special needs that are not met by mainstream services. Moreover, the mainstream service delivery system is ill-prepared to establish the kinds of service-oriented relationships that effective work with this particular population requires, a fact that has only served to further alienate these youth.

In response to the complex and largely unmet service needs, street outreach programs have begun to develop a wide range of services tailored to the specific needs of these youth. Outreach workers engage youth on the streets, providing crisis intervention, AIDS prevention information and materials, and assistance with food and shelter. Youth are encouraged to utilize drop-in center services that include both daily living needs (food, clothing, shower, etc.) as well as a wide array of counseling, educational, and health services. Both street-based services and those provided in the drop-in centers are designed so as to afford youth with as much flexibility as possible, focusing particularly on needs identified by the youth themselves and working at a pace that is also in large part determined by them.

Providing ready access to health care has become a central goal of these programs and an especially important part of their AIDS prevention strategy. A recent evaluation of AIDS outreach services targeted to these youth compared service delivery outcomes of street youth who had been contacted by street outreach programs and an especially important part of their AIDS prevention strategy. A recent evaluation of AIDS outreach services targeted to these youth compared service delivery outcomes of street youth who had been contacted by street-based prevention services (e.g., needle exchange programs, religious groups, soup kitchens, etc.). Youth contacted by street outreach were found to be much more likely to have sought health care services, AIDS testing and counseling services, treatment for an STD, and treatment for substance abuse, clearly indicating the efficacy of street outreach as a bridge between youth on the streets and critical prevention services such as health care. And yet, with limited existing resources, these outreach programs are only able to reach about a third of the youth in need, leaving much of this population to fend for themselves in the vagaries of the streets economy. For these later youth, illness, incarceration, suicide, and death from diseases such as AIDS are likely outcomes.

SUMMARY AND CONCLUSION
Numbering in the thousands, street youth suffer the cumulative "harm" of the loss of their childhood and of like on the streets. Faced with overwhelming feelings of self-doubt and self-blame, many turn to the ephemeral comfort of crack-cocaine and the numbing effects of alcohol and opiates. Lost in a downward spiral of self-destruction, many become dependent upon the street economy and increasingly vulnerable to the lack of power they exercise within this exploitative and violent system of exchange. Some of these youth will survive and eventually find a way out of street life. Many others will be lost to violence and self-destruction.

The life stories of these youth indicated that disease outcomes, especially those associated with HIV/AIDS, are unlikely to be prevented by simplistic notions of these youth "pulling themselves up by their boot straps. " Such an approach is based on the mistaken assumption that the problem is entirely, or primarily, a matter of altering youths' knowledge and psychological response to the health risks. The fact is that the vast majority of the homeless youth in New York City, and indeed, homeless youth throughout the world, are at risk not just because of inadequate knowledge, mistaken beliefs, or failures of intention, but as a result of systemic factors, in particular, social and economic inequities. Certainly the development of appropriate intervention messages, materials, and programs is an important public health goal. But we also need to confront the systemic conditions - poverty, lack of education, sexual abuse, homophobia, and limited employment opportunities-that propel these youth into high-risk situations and prevent them from leaving street life.

One youth, who described his living on the streets as "no money to ear, " has found that by joining an outreach program he's able to "get by." He explained:

I go there, and they help me a lot. And I think it's an extremely good program. It helps the youth today, and it keeps kids off the street [during the daytime]. You know, it gives them, like a future. And in actuality it helps them focus better on their future. 'Cause we all have a future. We don't know what it's going to be.'

The hope is that the future of this young man, and of the thousands of youth on the streets like him, will offer more promise than that of just "getting by." However, neither the short-term survival and security needs (food, shelter, and a feeling of safety and of belonging) nor the long-term goals of education, health, and employment, will be met as long as these youth continue to be invisible to, and ignored by, those who control the resources needed to protect and nurture them. Nor will they be met if the goals of public health policy are subverted through mechanisms of social control - surveillance, blame, and punishment. The scope of this chapter does not permit an exhaustive examination of the many policy issues that are emerging in relation to this growing and fragile population. We have, however, attempted to take the first step that should attend any policy process - namely, listening to the voices of the youth themselves.