Abstract

This ethnography was conducted in Barcelona, a city that provides different gay leisure resources, such as gay saunas. We aimed to analyze from studies on gender and masculinities, how sexuality, perception of HIV infection and other sexually transmitted infections (STIs), and preventive measures are articulated in gay sauna male sex workers (MSW). Ten in-depth interviews and observation were conducted between 2012 and 2016. Safe sex practices are more frequent with clients, while risk practices are carried out more with non-commercial partners. Sexual orientation plays an important role. Homosexuals assume riskier practices in sex work than heterosexuals. Drug use or lack of support networks were associated with higher social vulnerability and risk behaviors. Contracting HIV still creates fear, while having other STIs is perceived as part of a man’s sexual life. The MSW affirms masculinity with concurrent sexual partners, breadwinner, and on the other hand, questions a heteronormative model. Interventions for the prevention of HIV and STIs in this group should consider social determinants such as inferior work alternatives and the provision of more significant social support.

Key words
Sex work; Masculinity; HIV; Ethnography; Sauna

Introduction

Male sex workers (MSW) defined as men who sell or exchange sex for money or goods are a very diverse population among different countries, and even within the same country¹1 Baral SD, Friedman MR, Geibel S, Rebe K, Bozhinov B, Diouf D, Sabin K, Holland CE, Chan R, Cáceres CF. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2014; 385(9964):260-273.. Although MSWs offer sexual services to men and women, male clients are much more frequent²2 Bayer AM, Garvich M, Diaz DA, Sanchez H, Garcia PJ, Coates TJ. "Just getting by": a cross-sectional study of male sex workers as a key population for HIV/STIs among men who have sex with men in Peru. Sex Transm Infect 2014; 90(3):223-229.. Besides the risk involved in the practice of anal sex, several social determinants such as having limited economic opportunities, the lack of legislation and protective policies in matters of sex work (SW) and the invisible nature of this activity place MSWs in a position of vulnerability to contracting HIV and other sexually transmitted infections (STIs)³3 Programa Conjunto de las Naciones Unidas sobre el VIH/Sida (ONUSIDA). Trabajo Sexual Y VIH / SIDA. Genebra: ONUSIDA; 2003..

At the Spanish level, the self-reported prevalence of HIV was 17.5%⁴4 Ministerio de Sanidad SS e I. Encuesta "on-Line" europea Para Hombres Que Tienen Relaciones Sexuales Con Hombres: (EMIS):Resultados En España [CD-ROM]. Madrid: Ministerio de Sanidad; 2013. in a sample of 487 men who declared having sex in exchange for money. In Barcelona, of 548 MSWs presumably seronegative to HIV or with unknown serology and submitted to a rapid test in gay saunas, 8.7% were reactive to this test⁵5 García De Olalla P, Jacques Aviñó C, Martín S, Díez E, Fernández M, Santoma M, Roldán L, Andrés A, Caylá JA. Programa saunas de Barcelona: la vulnerabilidad de los trabajadores sexuales. En: SESPAS, editor. XXXIV Reunión Científica de la Sociedad Española de Epidemiología. Sevilla: Gaceta Sanitaria; 2016. http://www.reunionanualsee.org/2016/documentos/gaceta_Sanit_Reunion_SEE_2016.pdf.
http://www.reunionanualsee.org/2016/docu... . However, studies on male sex trade are scarce since research on HIV and other STIs usually include it in the category of men who have sex with other men (MSM) or within the group of people engaged in prostitution, which include women and transgender, groups with very different characteristics¹1 Baral SD, Friedman MR, Geibel S, Rebe K, Bozhinov B, Diouf D, Sabin K, Holland CE, Chan R, Cáceres CF. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2014; 385(9964):260-273..

Prostitution is alegal in Spain; it is not regularized or penalized, what is condemned is pimping, the fact of forcing someone into prostitution and obtaining benefits from it. The press and the media set Spain as one of the leading destinations for those seeking paid sex⁶6 Velasco HI. España, destino de turismo sexual. El Mundo. [citado 2016 Oct 13]. Disponíble en: http://www.elmundo.es/sociedad/2016/10/13/57fe88b2e5fdea63208b4583.html
http://www.elmundo.es/sociedad/2016/10/1... . Barcelona provides resources for leisure and consumption of paid sex aimed at the homosexual public, as well as places to have sexual relationssuch as gay saunas⁷7 Villamil F, Jociles M. Etnografía y prevención del VIH en el ambiente sexual madrileño. In: Alfonso OR, organizador. Antropología de la medicina, metodologías e interdisciplinariedad: De las teorías a las prácticas académicas y profesionales. San Sebastián: ANKULEGI Antropologia Elkartea; 2008.[informar las páginas del capítulo]. These places favor anonymous encounters for men to interact socially and sexually and are perceived as permissive and at risk of contracting HIV by the very users of these places⁸8 Downing MJ. Perceptions of HIV transmission risk in commercial and public sex venues. J Mens health 2012; 9(3):176-181.^,99 Jacques Aviñó C, García de Olalla P, Díez E, Martín S CJ. Explanation of risky sexual behaviors in men who have sex with men. Gac Sanit. 2015; 29(4):252-257..

Gender studies show how sociocultural patterns, social and sexual practices are modeling masculinities and influencing health¹⁰10 Connell R. Gender, health and theory: Conceptualizing the issue, in local and world perspective. Soc Sci Med 2012; 74(11):1675-1683.. The literature on this subject has focused mainly on the hegemonic model related to assuming risk behaviors, not showing weakness, and exhibiting a high degree of virility¹¹11 Courtenay WH. Constructions of Masculinity and their Influence on men's Well-being, a Theory of Gender and Health. Soc Sci Med 2000; 50(10):1385-1401.. They also point out that men are less willing to consult health professionals and express their fears despite worrying about their health, an exacerbated situation in less favored social classes and stigmatized diseases such as HIV/AIDS¹²12 Banks I. No man's land: men, illness, and the NHS. Br Med J 2001; 323(7320):1058-1060.

13 Möller-Leimkühler AM. Barriers to help-seeking by men: A review of sociocultural and clinical literature with particular reference to depression. J Affect Disord 2002; 71(1-3):1-9.^-1414 Mburu G, Ram M, Siu G, Bitira D, Skovdal M, Holland P. Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes. BMC Public Health 2014; 14:1061..

In this regard, ethnographic research is recommended in order to understand better the incidence, contexts, and risk behaviors associated with sexual relationsbetween men and transmission to their sexual partners¹⁵15 Programa Conjunto de las Naciones Unidas sobre el VIH/Sida (ONUSIDA). VIH y relaciones sexuales entre hombres. Genebra: ONUSIDA; 2006. Vol 82.. This study focused on indoor prostitution in a gay sauna, and aimed to analyze, from the perspective of masculinities, how sexuality is articulated, the perception of HIV infection and other STIs, and the preventive measures of MSWs that offer their services in gay saunas in Barcelona.

Methods

This research was developed from the socio-constructionist perspective, which proposes that people’s experience and statements are the product of social and historical processes. An exploratory and ethnographic study was conducted between 2012 and 2016 in a gay sauna in Barcelona, and 10 in-depth interviews with MSWs were held in 2015 and 2016. Observations were made in the sauna, and field notes were taken. In the sauna, the research team, consisting of a psychologist and anthropologist, two nurses and a doctor, participated in informal interactions with sex workers, clients, and employees of the establishment.

This study was carried out within the framework of the “Saunas Program” carried out by the Public Health Agency of Barcelona (ASPB), which consists of providing rapid tests for HIV, other STIs, and vaccination against hepatitis A and B in different gay saunas. Users collect the test results at the ASPB, where they receive counseling, and HIV positive cases are referred to hospital units for confirmation and treatment. The sauna was selected by convenience since it is one of the places where SW is exercised.

Semi-structured interviews were conducted, sociodemographic information was collected, and six topics on the experiences and beliefs of the MSWs were explored through a script (Chart 1). The interviews were recorded, except one, since the MSW wanted to keep his full anonymity. Once interviews were transcribed and field notes compiled, an interpretative thematic analysis was carried out to identify underlying ideas, assumptions, and conceptualizations from which categories and subcategories were established¹⁶16 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(May 2015):77-101.. The analysis was flexible and conducted throughout the fieldwork by researchers who participated in the observation and interviews, and was triangulated by experts in Public Health and Medical Anthropology. This study was approved by the ethical committee of the Hospital del Mar de Barcelona and with the informed consent of the respondents. Those who agreed to participate received a 10-trip urban transport card worth 10 euros as compensation.

Contact with participants

The interviews were provided to the MSWs contacted in saunas and those who came to collect the result after the tests were carried out. All interviews were conducted at the ASPB in order to preserve confidentiality and privacy. Of the twelve MSWs that were offered to participate, two refused, claiming that they did not want to talk about their sexual relationships with other men and both self-defined as heterosexual. Finally, ten MSWs from different countries were interviewed, four self-defined as heterosexuals, five as homosexuals and one bisexual. The possibility of adding some information was always left open, which allowed three of the informants to be interviewed more than once. The characteristics of the respondents are described in Chart 2. The study was closed when data saturation was reached.

Results

Six thematic categories were established: sex work in gay saunas; sex work: benefits and disadvantages; dynamics and social relationships in the sauna; sex work as a man; sexual practices by type of partner and HIV/STI/prevention. Chart 3 shows a selection of textual quotes from the interviews.

Sex work in gay saunas

The sauna is open 24 hours a day, and is equipped with swimming pools and offers spa services, as well as a bar and rooms freely available, and other more private rooms through extra payment. The user who enters receives a towel, pool sandals, a condom, and locker keys. This establishment does not obtain any direct economic benefit from the SW. What happens inside is a transaction that managers say is not their responsibility. The sauna exercises the right of admission, as commented by some MSWs: entrance is restricted, either through beauty criteria or for having caused some trouble before.

Among the benefits of working in the sauna, as opposed to offering sexual services in an apartment, the possibility of choosing the client, freely managing time and having greater economic autonomy was noted since the gain of transactional sex is an exclusive benefit of the MSW. Sauna MSWs are, in general, young gym-shaped and well-built bodies. Some MSWs spent the night in the sauna, especially those who worked seasonally in different Spanish or European cities, thus saving the rent of a room or house while residing in Barcelona.

MSWs referred to the sauna as “the office”, as a way to normalize the place and their professional activity. However, in one of the interviews, a self-defined heterosexual MSW called the sauna “hell”, since it was a place that questioned his sexual desire.

Sex work: benefits and disadvantages

The reasons for engaging in SW are diverse. In most cases, one enters through a friend or acquaintance. On the one hand, there were talks about the economic need related to emergencies experienced as extreme, such as paying rent or paying for the mother’s surgery in a foreign country. In other cases, it was out of curiosity, in men who felt homoerotic desires but lived in homophobic environments where it was hard to relate to other men.

Immigrant men in an irregular administrative situation were faced with very reduced and scarce employment opportunities, especially during the socio-economic crisis. Although there were some Spanish MSWs, most were from Latin American countries and Eastern Europe. The difficulty of entering the formal labor market was not only related to not having a work permit, and in some cases, to the low educational level but also having experienced structural racism. On the other hand, the most accessible labor alternatives for some MSWs crossed the threshold of legality, with which the SW became a good alternative.

One of the worst problems perceived by the MSWs was drugs. Drug consumption occurred at the customer’s request and to withstand long work hours. Indeed, some respondents commented that they started to consume in the sauna. The use of sexual stimulants was also widespread. Some MSWs also used drugs outside the workplace, at leisure or in other saunas. In some cases, they participated in chemsex a session, which involves the consumption of some drugs for sexual purposes for several days.

On the other hand, one could observe that, for some, the experience of having sex with men was lived with conflict, especially for heterosexuals or for those who had greater internalized homophobia. Another disadvantage mentioned was the lack of legal support regarding their rights as SW. Besides the risk of contracting diseases, they pointed out loneliness and that few people in the family or social environment knew what they were doing.

The economic benefits prevailed among the SW benefits. Depending on the days and the time of service with a client, one could earn up to 8,000 euros per month. The savings allowed buying homes in the country of origin, investing in training courses and sending money to their countries of origin to help support the family, as well as acquiring new cutting-edge devices (mobile phones, headphones, among others).

Dynamics and social relationships in the sauna

In general, the relationship with customers was appreciable. Problems emerged when someone did not want to pay what was agreed. Usually, the services that were requested were massages and sexual intercourse, but some practices could stress MSWs when clients requested MSWs to defecate or vomit on them. On the other hand, the demands did not always respond to sexual fantasies, since sometimes clients only wanted to share drug use or talk. The sauna was considered a good place to contact customers who later became fixed clients and with whom they could have relationships for years. Indeed, it could be the case that the client became a supportive relationship, not only economic but also emotional.

In an interview with a client, a retired doctor, he commented that the boys (MSW) held power in the relationship since an older man cannot have sex with a young and attractive man if it is not through payment. However, this was not the MSWs’ perception, which competed to attract the customer that could generate more significant benefits; in that way, the money became a demonstration of the client’s power in the relationship with the MSW.

Concerning the relationship with the MSW partners, we could observe how social relationships were established between those from the same country or “friendly countries”. It was also commented that they competed with each other, and sometimes some prejudice and racist attitudes emerged among the different groups, giving certain groups less social status. For example, Brazilians commented that they were the oldest in the sauna and those that generated the least problems. The few Hungarians there considered they had better education and economic status than the Romanians.

Sex work as a man

Few MSWs expressed shame or guilt for performing SW. Those who did were heterosexuals since money was considered a good source of compensation. Some did not feel identified as sex workers, but rather SW was understood as an activity that prolonged what is typical of men: having many and varied sexual intercourses.

Regarding the development of sexuality, what was commented is that the social, and not the institutional environment was the source of sexual education. For example, observing sexual experiences during childhood or living in environments where social relationships were mediated by strong erotic content, especially in MSWs from Latin American countries. In one case, sexual abuse was reported at puberty. The respondent hinted that it was the reason he had sex with men.

The MSWs that agreed to participate in the interviews indicated that they had no prejudice towards homosexuality, although their culture of origin (religion, family, and the like) stigmatized it. Instead, we could see how some MSWs showed rough masculinity and claimed that they only liked women, denying their sexual desires towards men.

The typical characteristics of men included honesty, fulfillment of certain obligations, being good people, and having a good job. Statements that pointed to man as an irrational being who only seeks sex also emerged. Although men were referred to as equals, the interviews evidenced gaps between homosexuals and heterosexuals, although some doubted that there were heterosexual men in the sauna. It was commented that homosexuals fell in love more easily, were more sensitive and more vicious than heterosexuals, which led to greater risk-taking. The fact of having a stable partner led the MSWs to adopt more preventive measures for fear of infecting him.

MSWs stated that clients are looking for men with traditionally manly traits, male models that respond to beauty criteria related to strength and youth. However, one MSW said that masculinity was not there to show certain patterns but to assume specific values.

Sexual practices by type of partner

In general, the MSWs associated the risky sexual practices with the fact of not using the condom in anal or vaginal sex, although they also related it with kisses, putting the fingers in the anus or with anal penetration without ejaculation. Sexual practices and prevention measures were different with non-commercial sexual partners and clients.

Condom use was more frequent in paid sex, while with non-commercial couples, where relationships sought pleasure, there was less condom use, especially after some time of relationship. That is, there was a higher perception of risk towards customers than with non-commercial partners. However, on one occasion, for a large sum of money associated with a perception of trust, one of the MSWs did not use the condom with a fixed client and became infected with HIV.

MSWs believed that homosexuals were more exposed to STIs since their sexual relations was mediated by pleasure, not only in the context of occasional partners but also among the MSWs partners, when, for example, a client requested to perform group sex. In the case of heterosexual MSWs, pleasure was also related to lower levels of prevention measures, but with women. Some of them believed that the only preventive measure was to be tested for HIV periodically. Another essential element was the need to feel sexually desired where situations of loneliness, lack of supportive social networks, and search for affection were factors that increase the vulnerability to participate in risky sexual encounters.

HIV/STI/Prevention

The perception of HIV infection and STIs is different. In the case of HIV, social stigma and fear persist, and in some cases, it was related to a death sentence, which led to some MSWs not wanting to be tested. Some statements also expressed serophobia; that is, they refused to have sex with people with HIV. There was a perception that people with HIV engaged in riskier sexual practices, and some claimed that all clients had this infection.

The perception of STIs was more normalized, considering that they were part of active sex life. An MSW living with HIV infection said that hepatitis was more dangerous and destructive than HIV but that the other MSWs were not aware of it. On the other hand, it was noted that there was no talk about STIs or other preventive measures among friends, or in the sauna environment. Also, being under the influence of drugs led to forgetting safe sex practices.

Concerning access to the health system, the difficulties and lack of knowledge about obtaining the individual health card (TSI) were discussed among the barriers. During fieldwork, one MSW who had had a receptive anal penetration without a condom, a high-risk practice of HIV infection, was not given post-exposure prophylactic treatment because he did not have the TSI. On the other hand, there was a perceived easy acquisition of drugs in pharmacies, so it was not surprising that immigrant MSWs who had been residing in Spain or Barcelona for years had no TSI, since they did not consider it especially a priority. When a suspected STI emerged, and they did not go to an emergency care center, they bought the medications they had previously used or followed the advice of a partner. In some cases, those who did not have a TSI and required medical care used the private health system. A Senegalese MSW used medicinal plants for disease prevention shipped from his country.

Concerning the intervention proposals, in general, they expressed low expectations. On the one hand, it was commented that the problem was in the individual who, as a result of loneliness and other social problems, did not care about himself and his health. On the other hand, it was pointed out that they had information to prevent HIV and other STIs and that, also, thank to information and communication technologies, it was easily accessible.

The lack of prevention campaigns was commented, although they were not perceived especially necessary since the “bad life” that some people led generated poor self-care. The sauna was perceived as a place where it was challenging to be healthy. An informant said that the prevention proposals required “removing them from the sauna and taking them to the countryside to see flowers”. The need to facilitate access and supply of condoms in gay leisure venues was noted.

Concerning the Pre-Exposure Prophylaxis, they commented that it was a good measure to prevent HIV, especially for those engaging in SW, although these would lead to decreased condom use. It was also said that some would continue using the condom since this treatment does not prevent other STIs.

Discussion

This is an ethnographic work carried out in a gay sauna that addresses the sexual and social relationships of MSWs from a gender perspective. This study shows that SW is articulated based on masculinity characterized by having multiple sexual partners, a virile appearance, and the ability to generate money as a strategy to achieve status. This pattern responds to a hegemonic cultural model associated with domination, social ascent, and holding hierarchy positions¹⁷17 Connell RW. Hegemonic Masculinity: Rethinking the Concept. Gend Soc 2005; 19(6):829-859.. On the other hand, the MSW questions the heteronormative model where identity, desire, and sexual behavior coexist in relationships among men. Thus, living in a city like Barcelona allows you to explore and live homosexuality with greater freedom and anonymity, since it has places that facilitate social and sexual encounters among men, such as saunas⁹9 Jacques Aviñó C, García de Olalla P, Díez E, Martín S CJ. Explanation of risky sexual behaviors in men who have sex with men. Gac Sanit. 2015; 29(4):252-257.. These establishments open options for interactions, where homosexuality and heterosexuality can be drawn together, and to some extent, integrated into the erotic field of same-sex practices¹⁸18 Parker R. Cambio de sexualidades: masculinidad y homosexualidad masculina en Brasil. Alteridades. 2002; 12(23):49-62.. Indeed, the MSWs that are presented from a heterosexual model feed the erotic fantasy of a rough, strong, and protective masculinity. Moreover, in gay iconography, an essential part of the texts realize that the homophobic cult of virility is not a heterosexual specificity¹⁹19 Welzer-Lang D. La mixité non ségrégative confrontée aux constructions sociales du masculin. Rev Fr Pedagog. 2010; 171.. On the other hand, the results show, as in other studies, that economic aspects or sexual desires invite the SW²⁰20 Lorway R, Reza-Paul S, Pasha A. On Becoming a Male Sex Worker in Mysore. Med Anthropol Q 2009; 23(2):142-160.. Also, money is linked to independence and the aspiration of material consumption, which give prestige, control over work, and self-development²¹21 Kong TS. Sex and work on the move: Money boys in post-socialist China. Urban Stud 2017; 54(3):678-694.^,2222 Nureña CR, Zúñiga M, Zunt J, Mejía C, Montano S, Sánchez JL. Diversity of commercial sex among men and male-born trans people in three Peruvian cities. Cult Health Sex 2011; 13(10):1207-1221.. Therefore, SW allows achieving an economic and social status that outweighs engaging in a socially stigmatized activity.

The stigma of engaging in SW adopts differences by gender: while in women, the fact of having multiple sexual partners is morally questioned, men are encouraged and even allowed a greater right to leisure and pleasure²³23 Juliano D. La Prostitución: El Espejo Oscuro. Icaria. Barcelona; 2002.. The stigma in them is produced by having relationships with men. Indeed, some young people believe that MSWs become an option to “come out of the closet”, especially for those who had few options to have homosexual relationships in their environment. From a health perspective, it has been shown that there is an association between being attracted to someone of the same sex and worse self-perceived health, more problems with chronic disorders and increased consumption of alcohol and other drugs²⁴24 Pérez G, Martí-Pastor M, Gotsens M, Bartoll X, Diez E, Borrell C. Salud y conductas relacionadas con la salud según la atracción y la conducta sexual. Gac Sanit 2015; 29(2):135-138.. It should also be considered that in a market with precarious work alternatives, it influences the ethnic employment segmentation. That is, immigrant or ethnic minorities’ MSM who experience more significant racism and economic deprivation find a work alternative in the sex market, albeit with a higher proportion of unprotected sex and greater vulnerability to contracting HIV²⁵25 Lewis NM, Wilson K. HIV risk behaviours among immigrant and ethnic minority gay and bisexual men in North America and Europe: A systematic review. Soc Sci Med 2017; 179:115-128..

A vital element of this study was to consider sexual orientations, desire, and their relationship with sexual practices in the sauna’s MSWs. Despite adopting an attitude of complacency towards the client, prevention measures were assumed, while this changed with non-commercial sexual partners, whether they were men or women. Those who self-defined as homosexuals engaged in riskier sexual practices in the context of the sauna than heterosexuals, who experienced more significant conflict in this environment. It has been hypothesized that MSWs that are defined as heterosexual or bisexual may have more symptoms of depression or anxiety, respectively, which varies according to the definition of sexual orientation and attitude towards homosexuality²⁶26 Bar-Johnson M WP. Mental health and sexual identity in a sample of male sex workers in the Czech Republic. Med Sci Monit 2014; 20:1682-1686..

On the other hand, situations such as loneliness or lack of supportive social networks were associated with lower self-care. In this regard, it is essential to consider a syndemic approach that allows explaining behaviors from different levels, as well as the social determinants of health²⁷27 Tsai AC, Mendenhall E, Trostle JA, Kawachi I. Co-occurring epidemics, syndemics, and population health. Lancet 2017; 389(10072):978-982.. From this perspective, the importance of having the social support of family and friends has been shown, since the absence of social capital is a factor that promotes risky sexual practices and, thus, the vulnerability to contracting HIV and other STIs²⁸28 Hart TA, Noor SW, Adam BD, Vernon JRG, Brennan DJ, Gardner S, Husbands W, Myers T. Number of Psychosocial Strengths Predicts Reduced HIV Sexual Risk Behaviors Above and Beyond Syndemic Problems Among Gay and Bisexual Men. AIDS Behav 2017; 21(10):3035-3046.. It should also be noted that STIs are perceived, unlike HIV, as part of a man’s sexual life.

It is also essential to address the issue of drugs, consider the interrelation between the subject, the substance and the socio-cultural contexts in which consumption occurs²⁹29 Romaní O. Las drogas. Sueños y razones. Ariel S.A.: Barcelona; 1999. to understand better, for example, the emergence of the Chemsex phenomenon and increasing sexual practices that facilitate the transmission of STIs. Therefore, it would be advisable to exchange knowledge between STI services and drug specialists, as well as identify the reasons that lead people to participate in these practices³⁰30 Frankis J, Clutterbuck D. What does the latest research evidence mean for practitioners who work with gay and bisexual men engaging in chemsex?? Sex Transm Infect 2017; 93(3):153-155..

One of the limitations of this study was not having dwelt further on the MSW’s knowledge about STIs, although attitudes towards prevention and care could be explored. On the other hand, the observation time in the sauna was sufficient and led to information saturation. There are few opportunities to participate so continuously and regularly in this environment, a factor that allowed to create the necessary confidence for contact with informants. Besides, we must consider that studies on MSWs are increasingly complex, due to the use of apps that facilitate sexual contacts with clients online and via meetings in private quarters³¹31 Ryan P. #Follow: exploring the role of social media in the online construction of male sex worker lives in Dublin, Ireland. Gender, Place Cult. 2016; 23(12):1713-1724..

All of the above allows us to reflect on what SW implies in men. On the one hand, it increases economic and social status, and can even become a platform for emotional networks. On the other, it means entering a world where risk and harm to personal and community health coexist with essential repercussions for one’s well-being. This topic should be further analyzed and include MSWs’ clients since they can provide valuable information on the established power relationships, the mechanisms of economic transaction, and negotiation of sexual and social practices.

In a nutshell, it was observed that risky sexual practices occurred mainly with non-commercial sexual partners. Desire and pleasure mediated relationships, which meant that the MSWs self-defined as homosexuals engaged in less safe sexual dynamics. On the other hand, using drugs, not having a steady partner, and not having supportive social networks are factors that increase the MSWs’ social vulnerability. The interventions for the prevention of HIV and STIs in this group would have to consider the social determinants and needs of the MSWs, create synergy with the owners and workers of these establishments, the health system, community entities and public health in order to respond to complex problems that foster a model of masculinity aimed at better personal and community care.

Acknowledgments

The authors are grateful to the study’s informants and those responsible for the sauna, whose collaboration was essential for this work.

Partial backing was received from CIBERESP.

References

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