Read Male Sex Work and Society Online
Authors: Unknown
Tags: #Psychology/Human Sexuality, #Social Science/Gay Studies, #SOC012000, #PSY016000
Male Sex Work and Society (71 page)
Studying the Health of Male Sex Workers
While the earliest studies on male sex workers were underpinned by deviancy discourses, the HIV/AIDS epidemic heralded a new era and tone in research. Studies have since focused on behavior and practices to minimize the spread of STIs and called for more comprehensive social and health services. A recent national progress report on HIV conservatively estimates its prevalence among MSWs in Germany at 5 percent to 10 percent (UNAIDS, 2012). Other studies focused on this population have found higher rates, ranging from 27 percent prevalence of STIs and 15 percent of HIV (Wright, 2001) to an overall STI rate of 24 percent to 33 percent (Steffan & Sokolowski, 2008). While new HIV infections in Germany have declined over the years, an estimated 75 percent of syphilis cases are among men who have sex with men, and up to 50 percent of these men are considered likely to be HIV positive (Marcus, Bremer, & Hamouda, 2004). Research findings overall suggest very good knowledge of transmission risks among the German population of men who have sex with men. However, more risky behaviors have been reported with the advent of highly active antiretroviral therapy, along with a trend toward having more sexual partners and unprotected anal intercourse; condom use based on the real or perceived HIV status of sexual partners (“serosorting”); sexual role assignments (insertive versus receptive) based on HIV status (“seropositioning”); and seeking sexual partners on the Internet (Marcus, Voss, Kollan, & Hamouda, 2006). One study concluded that about 40 percent of MSWs in Germany did not use a condom with regular clients who paid more, and that only a third knew where they could receive anonymous HIV testing (Steffan & Sokolowski, 2008). Migrant MSWs were especially poorly informed about the risks associated with specific sex practices.
Many MSWs describe themselves as heterosexual and are involved in intimate relationships with women, with whom they often avoid open communication about their same-sex behavior. Moreover, MSWs are more likely to use condoms with paying partners than in intimate private relationships (Padilla, 2007; Parsons, 2005; Wright, 2003). Indeed, men who practice bisexual behavior eventually became a central focus of HIV research because of the associations between sexual risk behavior, serostatus, and disclosure. The bridge model of the late 1980s considered bisexuality to be narrowly contained within a small group of “risky men” and thus singled out male sex workers as central to the spread of HIV to the general population (Aggleton, 1996). This approach neglected to contextualize disclosure patterns within broader experiences of social inequality and stigma management. Researchers continue to debate the role disclosure of HIV status plays in safer sex practices (Padilla et al., 2008), with some suggesting that nondisclosure does not necessarily equate with higher sexual risk for HIV. Men who migrate are at increased risk for HIV infection and face a number of barriers affecting disclosure to their stable female partners (Hirsch, 2003; Padilla, 2007). Furthermore, claims reporting condom use among a definitive percentage of sex workers should be viewed with skepticism, as this assumes there is a fixed MSW population, which is a “fiction” (Altman, 1999). Human interactions and relationships follow a continuum, and many sexual transactions may involve people who do not identify as sex workers. The outbreak of HIV meant that “grudging attention came to be paid to … ‘men who have sex with men’ (a clumsy phrase adopted to overcome the confusion of identity with behaviour)” (Altman, 1999, p. xiii). One danger in the literature that frames sex work as the product of economic necessity is that the sexual orientation of male sex workers is always questioned, whereas female sex workers are often assumed to be heterosexual (Dennis, 2008). By overemphasizing that many MSWs are not “really” homosexual, researchers may have fueled one of the great panics of the HIV epidemic, namely, the fear that male sex workers would serve as “vectors” of infection to the “general” community (Altman, 1999).
Because of the bridge effect and a fixation on bisexuality, most research evaluating the health needs of MSWs has emphasized HIV rather than general health concerns or high rates of violence (Dennis, 2008). However, their multiple interrelated vulnerabilities put them at risk for a number of health problems beyond STIs (Wright, 2003). One of the only studies of German MSWs that mentions non-STI health problems noted that they were “diverse but within normal range” (Steffan & Sokolowski, 2008). While the authors did not elaborate further, this suggests a pattern typical for this age group, including sporadic acute health issues and lower rates of chronic disease. Few studies have examined actual male sex workers’ access to health care and use of health services.
Health-Care Access and Primary Complaints
The remainder of this chapter will focus on health concerns among migrant MSWs, the most serious of which is a lack of health insurance. In Germany, selling sex is considered a legitimate economic activity and people working in the sex industry are entitled to participate in the social welfare and health-care systems. Most migrant MSWs, however, are not officially registered as residents, often because they cannot afford to rent an apartment on their own so they cannot obtain the small business license required to indicate this as their primary employment. Even if they are legally registered, they may be unable to afford health insurance, which can cost 250 euros (US$300) or more a month. While assistance is available to help low-income earners maintain health insurance, social workers note that they have difficulty obtaining information about benefits because of their clients’ unclear status as EU citizens. One noted that she calls government offices on behalf of MSWs, but “they always just say, ‘send in the application and we’ll let you know what other paperwork is required.’ But then you never hear back, or they just reject this application with no explanation.” If MSWs later enter a different field of employment with a legal work permit, they often have to pay retroactively to enter the statutory health insurance system, beginning when they registered as having entered the country. This often means paying thousands of euros.
Because they lack health insurance, many MSWs access care at the weekly medical consultations offered through the drop-in centers. Physicians are sometimes provided by the local health department, while others are volunteers or retired doctors. The following sections draw upon interviews with physicians, social workers, health department staff, and male sex workers, as well as annual reports from organizations providing assistance to male sex workers in eight major cities: Berlin, Hamburg, Frankfurt am Main, Cologne, Stuttgart, Munich, Dortmund, and Essen. In 2011, the Berlin organization serving men who have sex with men whose reports were reviewed for this study provided 354 medical consultations (Subway, 2012). Over the last seven-and-a-half years (2005 through mid-2012) it has provided 2,603 medical consultations to at least 756 individuals. The Frankfurt organization provided care to 91 patients (KISS, 2012), while the Cologne organization provided 456 consultations on health-related issues and accompanied 41 people to medical services (LOOKS, 2012). The Berlin organization also has a mobile clinic that is set up outside local bars 12 times a year and advertised through street worker outreach and word of mouth. While much in demand, services are limited because of time and space constraints, as well as low levels of lighting that impede thorough physical examinations. Physicians must improvise for the medications or treatments they offer. Some young men are sent to the hospital for emergencies such as appendicitis or injuries from a fight, and many mobile consultations involve testing and vaccinating for hepatitis. The physicians and staff interviewed for this study noted that the young men’s knowledge of health and bodily processes was poor, which, coupled with language barriers, often led to misunderstandings.
An overview of major health concerns for MSWs can be found in the annual reports of these organizations, along with additional medical data provided by one of the organizations. Physicians working with this population primarily encounter illnesses associated with lifestyle and poverty. At the Berlin organization, 77.2 percent of all medical visits were for issues unrelated to STIs (Subway, 2012). Another organization reported that the main illnesses, in order of frequency, were respiratory (28.6 percent), dermatological (17 percent), urological (13.2 percent), back pain (9 percent), toothache (6.5 percent), headache (5.5 percent), and injuries (5.5 percent; KISS, 2012). The physicians interviewed noted that the primary medical conditions for which migrant MSWs seek help are general concerns such as headaches, stomachaches, and fungal infections. These issues stem from a lack of personal care by those living on the streets without regular access to health care. One doctor noted, for instance, that “nail fungus can be easily treated—most people are able to go to the pharmacy and obtain topical medication. But these boys are in bars two or three nights straight, often without sleep, showers, food, and clean clothing, and as a result the problem becomes worse and worse until it is unbearable.” Lice and bedbug bites are common problems resulting from sleeping in crowded, unhygienic conditions. Other young men face the unpredictable illnesses typical for this age group, such as a hernia requiring surgery. Describing one such case, a physician stated that there was little chance of a breech, but “the boy was in pain and we can’t let him just continue to walk around like that,” so a low-cost surgery was negotiated with a local hospital. Violence, usually fighting, was noted to be a common cause of injury that was not addressed in weekly clinics, as such injuries are often severe enough to send men straight to the emergency room.
Some physicians stated that they were unable to adequately address mental health issues, even though many young men report somatic symptoms and depression. Some organizations work with volunteer psychologists, but their time and ability to provide therapy is very limited. The nature of sex work remains difficult for many, and some men cope by turning to alcohol or smoking hashish. Cigarette smoking is universal. Other drugs are generally not used, although a few men report occasionally consuming cocaine provided by clients. This is in line with results from a prior study, which concluded that most substance use involved alcohol, cannabis, and poppers (Steffan & Sokolowski, 2008).
In the words of a staff member from one of the organizations serving MSWs, dental issues are considered “a huge problem with no clear solution.” One organization reported that they used to send men for free dental services at a local homeless shelter, but this is no longer available because, to protect their own funding stream, the shelters no longer serve migrants. One organization has a private dentist in its network who will take some patients for a small fee. However, as one physician noted,
when you start taking people, as a dentist you either have to open your door to many, or you have to set strict limits. Some dentists will say, “Oh, but I’ve already taken three this year,” or ask, “Is it an emergency?” She says indignantly, “How do I know if it’s an emergency? This person is in pain, bad pain. Crying in front of me. When exactly does that become an emergency?”
Most dentists, she claimed, do not understand the limitations associated with the migrant MSWs’ lifestyle. She gave the example of a young man who showed up late at a dentist’s office and was refused to be seen. As she explained, “You can’t do that with this population, they don’t know their way around the city; it’s sad, they may live here for years but stay in one area, and thus have never really explored Berlin.” Or, she added, they may have had an appointment with a paying client during the day: “You just can’t schedule like that for this population.”
Referrals are a common part of the weekly medical visits, mobile clinics, and social work consultations. MSW clients are referred directly to the health department for STIs, but are otherwise sent to charity or nonprofit clinics. One physician stated that she “has to be careful about which boys I send to which organizations, because some are more judgmental than others.” This is because of the stigma associated with being a sex worker and Roma. At the same time, she noted, many Roma are reluctant to go to the doctor because they have had bad experiences in the past and have “been treated differently their whole lives. Many have never been to a doctor before … So, you are negotiating these two positions.”
“Hustling Is Hustling, It Has Nothing to Do with Your Sexuality”: STIs, HIV, and Sexuality
HIV and other STIs are a major focus of medical consultations and health education efforts, even if the most common medical problems encountered are unrelated. Migrant MSWs are at high risk for HIV infection for a number of reasons. First, a lack of job options, language barriers, and an insecure housing situation mean they are pushed to work in riskier settings. This leads to more dependency, greater competition, and higher susceptibility to violence, all of which influence their willingness to engage in riskier sex practices. Second, social workers and physicians report that migrant MSWs have little knowledge of STIs, which they attribute to a lack of formal education and the fact that the men are quite young and inexperienced. With an average age of 21, they enter into sex work largely without instruction or mentorship, and they are ill informed about the possible threats to their health and thus willing to take risks. They rarely discuss their experiences or possible dangers, such as a client refusing to use a condom. In interviews and health education sessions, the misinformation they encounter comes to light. For example, some believe that HIV infections can occur only after a series of other diseases, so one first acquires gonorrhea, then syphilis, and only then is susceptible to HIV. Many believe that one can “see” if someone is HIV positive based on their general habits and grooming; one said that “if a person is [physically] dirty, I just don’t go with him.” These beliefs, along with few years of formal schooling, a lack of German language skills, and, in some cases, illiteracy, hamper preventive health efforts.
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