Stigma, social inequality, and HIV risk disclosure among Dominican male sex workers

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Abstract

Some quantitative behavioral studies in the USA have concluded that bisexually behaving Latino men are less likely than White men to disclose to their female partners that they have engaged in same-sex risk behavior and/or are HIV-positive, presumably exposing female partners to elevated risk for HIV infection. Nevertheless, very little theoretical or empirical research has been conducted to understand the social factors that promote or inhibit sexual risk disclosure among Latino men who have sex with men (MSM), and much of the existing literature has neglected to contextualize disclosure patterns within broader experiences of stigma and social inequality. This paper examines decisions about disclosure of sex work, same-sex behavior, and sexual risk for HIV among male sex workers in two cities in the Dominican Republic. Data derive from long-term ethnography and qualitative in-depth interviews with 72 male sex workers were used to analyze the relationships among experiences of stigma, social inequality, and patterns of sexual risk disclosure. Thematic analysis of interviews and ethnographic evidence revealed a wide range of stigma management techniques utilized by sex workers to minimize the effects of marginality due to their engagement in homosexuality and sex work. These techniques imposed severe constraints on men's sexual risk disclosure, and potentially elevated their own and their female partners' vulnerability to HIV infection. Based on the study's findings, we conclude that future studies of sexual risk disclosure among ethnic minority MSM should avoid analyzing disclosure as a decontextualized variable, and should seek to examine sexual risk communication as a dynamic social process constrained by hierarchical systems of power and inequality.

Introduction

The questions of when and under what circumstances individuals disclose information about their sexual risk behaviors or HIV status to their primary partners have been central to recent scholarly debates about the epidemiological importance of sexual disclosure in the age of AIDS. As some research has suggested that rising infection rates among ethnic minority women may be related to the clandestine bisexual behavior of their male partners (Bingham et al., 2002, Chu et al., 1992, Lehner and Chiasson, 1998, Stokes et al., 1993, Stokes et al., 1996, Stokes and Peterson, 1998), scholars have called for attention to the role of HIV risk disclosure – direct communication with sexual partners about one's sexual risk for or infection with HIV – as a potentially important factor influencing HIV transmission. A number of researchers have argued that disclosure of sexual orientation, sexual risk behavior, or HIV serostatus by bisexually behaving men may each play a role in preventing new HIV infections (Agronick et al., 2004, Bingham et al., 2002, Chu et al., 1992, Lehner and Chiasson, 1998, Montgomery et al., 2003, Norman et al., 1998, Shehan et al., 2003, Stokes et al., 1993, Stokes et al., 1996, Stokes and Peterson, 1998). Such assertions are driven by the belief that the disclosure of HIV risk may improve communication between sexual partners and, thereby, increase the likelihood that safer sex can be consistently practiced (Simoni & Pantalone, 2004).

Nevertheless, some research suggests that disclosure of HIV serostatus does not necessarily ensure safer sex practices (Crepaz and Marks, 2003, Marks and Crepaz, 2001, Marks et al., 1994, Millett et al., 2005, Serovich and Mosack, 2003) and that nondisclosure of HIV status does not necessarily translate into higher sexual risk for HIV (Marks and Crepaz, 2001, Millett et al., 2005, Poppen et al., 2005). Similarly, while some scholars have suggested that the disclosure of bisexual behavior to female partners is associated with increased condom use (Wolitski, Rietmeijer, Goldbaum, & Wilson, 1998), other research has not detected such effects (Kalichman, Roffman, Picciano, & Bolan, 1998). Compounding such inconsistencies, one recent meta-analysis of the literature on HIV serostatus disclosure has pointed to serious limitations in existing research due in part to a paucity of contextualized studies of how disclosure is actually understood and practiced in specific populations (Simoni & Pantalone, 2004).

Drawing on ethnographic and qualitative interview data with a population of bisexually behaving male sex workers in the Dominican Republic, this paper argues that much of the inconsistency in findings on HIV risk disclosure is related to the tendency to focus on individual-level or relational factors while neglecting the contextual factors that inform bisexually behaving men's decisions to disclose. Research should treat disclosure as a dynamic social process that unfolds within specific social, cultural, and economic contexts. Further, we suggest that studies of HIV risk disclosure would greatly benefit from existing social science approaches to stigma and social inequality as they have been applied globally in public health (Farmer et al., 1996, Link, 2001, Link and Phelan, 2006, Parker, 2001, Parker and Aggleton, 2003, Parker et al., 2000). This would allow researchers to examine the ways specific populations make decisions about disclosure in relation to the multiple social norms and power structures that they face in their daily lives.

Research among Latino men who have sex with men (MSM) is particularly relevant in this regard. Numerous qualitative studies have shown that these men are likely to encounter severe structural disadvantages, such as poverty, discrimination, disconnection from kinship structures, interpersonal violence, elevated unemployment, and low educational attainment (Carrillo, 2002, Díaz, 1998, Díaz et al., 2001, Díaz et al., 2000, Kulick, 1998, Lancaster, 1992, Padilla, 2007, Padilla et al., 2007, Prieur, 1998). Despite this, much of the public health research on HIV risk disclosure among Latino MSM has focused on decontextualized correlations, such as the finding that Latino men are less likely to disclose their same-sex sexual behaviors (McKirnan, Stokes, Doll, & Burzette, 1995), to identify as gay (Goldbaum et al., 1998, McKirnan et al., 1995, Montgomery et al., 2003), and to report sexual interactions with both females and males than are White MSM (Montgomery et al., 2003). While some serostatus disclosure studies have suggested that disclosure may be inhibited by the stigma of homosexuality in the Latino community (Zea, Reisen, Poppen, Echeverry, & Bianchi, 2004) or by a desire to protect family members from a damaged social reputation (Mason, Marks, Simoni, Ruiz, & Richardson, 1995), quantitative public health studies of HIV risk disclosure have generally failed to develop analyses that link the dynamics of disclosure to the social, cultural, and structural context of Latino and Latin American communities. Indeed, one recent study of HIV serostatus disclosure among HIV-positive Latino MSM concluded that “programs that encourage disclosure of serostatus…may not affect sexual risk behaviors unless they deal with the responses to the resulting knowledge of seroconcordance or discordance” (Poppen et al., 2005, p. 235).

The present analysis derives from a three-year, multi-method ethnographic study of male sex workers in the Dominican Republic, most of whom were bisexually behaving men with stable female partners (see Methods and background and Padilla, 2007). Male sex work in the Caribbean has received some attention in social scientific research – primarily as regards exchanges between Caribbean men and foreign women (Brennan, 2004, Kempadoo, 1999, Phillips, 1999, Press, 1978, Pruitt and LaFont, 1995). Nevertheless, little is known about the relationships among social stigma, social inequality, and HIV risk disclosure among male sex workers and their local female partners. As far as we are aware, this study represents the first analysis of these issues in the region.

Section snippets

Methods and background

Our research seeks to examine how members of a specific population of bisexually behaving Latin American men narrate real or potential moments of sexual disclosure with their partners and families, and to describe how experiences of stigma and social inequality shape their decisions, perceptions, and practices of disclosure. Data derive from an ethnographic study of male sex workers led by the first author in two cities on the southern coast of the Dominican Republic (Santo Domingo and Boca

Experiences of stigma and inequality

At age 9, “Miguel”,1 32 years of age at the time of his interview, left his family home and became, in his words, “a street kid”: “I was raised in the street. Mainly I was raised with the tourists. I worked with them. Some were gays and I stayed with them, and that's how my life went. I raised myself alone.” Two years after leaving home, he relocated from his home town of La Romana to Santo Domingo to try

Discussion

The participants in this study experienced significant social stigma due to their violation of norms of sexual behavior and modes of work. Interview and ethnographic evidence demonstrates sex workers' use of stigma management techniques to minimize the effects of these dual stigmas, including the invention of jobs to justify sex work income, the creation of alibis for extended absences, and the production of girlfriends to perform heterosexual normalcy. While many of these men described great

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  • The first author would like to thank several agencies which funded portions of the research: the Wenner-Gren Foundation for Anthropological Research, Fulbright IIE, the National Science Foundation, the Fogarty AIDS International Training and Research Program, and the Dominican Republic mission of the United States Agency for International Development. Many thanks to Luis Lizardo at Columbia University for his coding of the in-depth interviews. Finally, the authors would like to thank the courageous men who participated in the research.

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