Commentary: Sex trade involvement and rates of HIV-positivity among young gay and bisexual men

Alex Carballo-Diéguez and Ezra Susser

The Joseph L Mailman School of Public Health, Columbia University, 600 West 168 St, PH-18, New York, NY 10032, USA. E-mail: ess8{at}columbia.edu

Somewhat belatedly, the world has begun to officially acknowledge the catastrophic impact of HIV/AIDS. The Declaration of Commitment on HIV/AIDS adopted on 16 June 2001 by the United Nations General Assembly (Excerpts From the UN's Statement on AIDS, 2001)1 brought to centre stage the need for governments, civil societies, the business community and the private sector to act in concerted fashion to combat the pandemic. The potential for devastation is particularly strong in sub-Saharan Africa and in countries with vast populations like India and China. As the magnitude of these events in low-income regions dawns on the international community, it is tempting to consider HIV to be all but conquered in the wealthiest nations. It is not.

The epidemic continues to rage within some population groups in high-income countries, particularly on the North American continent. Young gay men are one of these groups. Recent reports of studies undertaken in seven US cities between 1998 and 2000 with men who have sex with men aged 23–29 show that HIV prevalence was 7% among whites, 14% among Latinos, and 32% among African Americans. Furthermore, while the overall incidence of HIV was 4.4%, it was 14.7% among African American young men (CDC, 2001).2

Young gay and bisexual men are the topic of the paper by Weber et al.3 in this issue of the International Journal of Epidemiology. In a prospective cohort in Vancouver, they examine which men are more likely to engage in sex trade work, a major risk factor for HIV. An important finding, though perhaps not a surprising one, is that some of the powerful determinants of social marginality and stigma are also related to sex trade work, for instance, being a former psychiatric inpatient, unemployed, or of aboriginal ethnicity.

The authors' choice of the terms ‘sex trade’ over the word ‘prostitution’ is an acknowledgement that the latter carries a strongly negative connotation. We need to understand how gay men involved in trading sex for goods view the stigma associated with the activity and how they cope with it. Indeed, trading sex is an activity that needs to be seen in its full social context. Consider the finding that aboriginal men were more likely to trade sex. Since one would be hard pressed to find a genetic relationship between ethnic origin and sex trade work, an understanding of this association requires one to consider the history of aboriginal individuals during the colonization of Canada, their current social situation, their access to education and employment, and other structural factors that may put the presented results in context. Ultimately this kind of analysis may suggest that interventions to reduce HIV transmission will fail if they overlook the mitigation of broad social and structural problems.

The trading of sex plays a central role in the HIV pandemic and we should examine it with the utmost rigour as well as sensitivity. ‘Sex trade’ is one of those concepts that seem clear only until the moment we try to define it. The apparently dispassionate ‘sex trade’ nomenclature is in fact extremely difficult to operationalize. Weber et al. define sex trade as ‘exchange of money, drugs, goods, clothing, shelter, or protection for sex within the one year prior to enrolment’. Although this broad definition of sex trade may be appropriate to get an initial impression of the proportion of people in a sample who engage in these behaviours, a finer distinction is needed if we want to gain any deep understanding of this experience and its connections to other observable variables. A number of dimensions need to be considered, for example:

Intentionality

Are both parties engaging in sexual activity with the understanding that a certain type of payment is involved? If there is no intentionality, can it be considered exchange? For example, if one man offers drugs to another one, and they both know that after they get ‘high’ they will have sex, is this an exchange of sex for drugs?

Type of good exchanged

Is there a difference between exchanging money for sex—even different amounts of money for different types of sexual acts—versus exchanging other goods e.g.—a place to spend the night —for sex? Is it sex trade if a sexual ‘favour’ is followed or preceded by some kind of present?

Frequency

Is the exchange of sex for goods a daily occurrence or only a sporadic event?

Number of partners

Is the individual exchanging sex for goods with many different partners, or is it always with the same partner?

History

Is the event a first time occurrence or is it part of an established pattern of behaviour for an individual?

Roles

Is the reporting individual paying or is he/she being paid for sex?

Choice

Is the respondent engaging in the exchange of money for goods as a last resort for survival or is he/she freely choosing this activity from many other possibilities?

Cultural milieu

Is the transaction sanctioned as acceptable in the specific cultural environment, or is it stigmatized?

Depending on the answers we give to these questions, sexual transactions may receive a variety of labels ranging from prostitution to marriage. Furthermore, some or all of these variables may interact with each other, altering the meaning of the exchange. For example, a young hustler may be exploited but may also exploit an older, wealthier patron. The dynamics of power in the exchange of sex and goods may hinge on many subtle elements, with emotions and personal needs playing an important role. Above all, there is need to understand the sexuality of young men who have sex with men in all its multifaceted complexity in order to lay the foundation on which to build programmes to promote healthy sexuality, free from disease, stigma, and violence.

References

1 Excepts from the UN's Statement on AIDS. The New York Times 29 June 2001, p.A8

2 Centers for Disease Control and Prevention. HIV incidence among young men who have sex with men—seven US cities, 1994–2000. MMWR 2001;50(21):440–44.[Medline]

3 Weber AE, Craib KJ, Chan K et al. Sex trade involvement and rates of HIV positivity among young gay and bisexual men. Int J Epidemiol 2001;30:1449–54.[Abstract/Free Full Text]





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