Housing Instability As a Determinant of Transactional Sex Among Adults Enrolled In Opioid Use Treatment Services

Background and Purpose: Housing instability is a key social determinant of health that is associated with numerous adverse health outcomes, including risk of exploitation or victimization. Transactional sex is the practice of trading sex for goods or necessities and represents a crucial public health concern. However, the prevalence of transactional sex among people with opioid use disorder (OUD) and its relationship to housing instability is understudied. This cross-sectional study provides current evidence on the association between housing status and transactional sex.

Methods: From July 2024 to June 2025, adults with OUD (N = 830) from 61 substance use treatment programs across 26 U.S. states completed an anonymous questionnaire assessing clinical and demographic characteristics and history of transactional sex. Housing status was operationalized as stable (rent/own) versus unstable or institutional (temporary housing, shelter, street dwelling, or institutional settings). Sociodemographic characteristics were compared using chi-square tests and independent-samples t-tests. Multivariable logistic regression was used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the association of housing instability with transactional sex, adjusting for sociodemographic and clinical factors.

Results: The sample was predominantly male (68.7%, N = 556), followed by female (30.8%, N = 249), and non-binary (0.5%, N = 4). The racial and ethnic composition of the sample included White (65.8%, N = 537), Black/African American (12.4%, N = 101), Hispanic/Latino (9.8%, N = 80), and people of other races (12.0%, N = 98). Most participants identified as heterosexual (87.1%, N = 723), while 9.5% (N = 7.6) identified as LGBTQ+. The mean age of the sample was 38.07 years (SD = 9.95). Past-year transactional sex was frequently reported (42.2%; n = 345). Among participants who reported transactional sex, the most common exchanges were for drugs (20.6%), money (17.2%), and housing (10.0%). Housing instability was common (65.6%, n = 391), including temporary housing (21.6%), shelter (12.2%), street dwelling (9.4%), treatment or recovery housing (10.4%), jail or hospital settings (3.2%), and other settings (8.7%). The prevalence of transactional sex was substantially higher among participants with unstable housing compared to those with stable housing (76.6% vs. 56.8%; χ²(1) = 25.40, p < .001). In multivariable models, housing instability remained strongly associated with higher odds of transactional sex (AOR = 3.02, 95% CI: 1.89–4.82, p < .001). Psychiatric treatment was associated with lower odds (AOR = 0.54, 95% CI: 0.36–0.83, p = .004), while age, gender, race, education, and sexual orientation were not significantly associated with transactional sex.

Conclusions and Implications: Among adults entering treatment services for opioid misuse, housing instability was strongly associated with engagement in transactional sex. Participants with unstable housing had more than threefold higher odds of reporting transactional sex compared to those with stable housing, even after adjusting for sociodemographic and clinical factors. These findings demonstrate that housing instability is a major structural factor contributing to health-risk behaviors. This study underscores the need for substance- and survival needs-focused interventions as part of comprehensive public health strategies to address housing instability.