Cruise control: bathhouses are reigniting the AIDS crisis. It's time to shut them down.

JUDGING FROM THE DESCRIPTIONS I'VE read and heard, the bathhouse I visited not long ago is fairly typical. Pay $8 to the clerk behind the Plexiglas window and he'll give you a towel and buzz you in. Inside are hallways of private rooms for sex, each about six by six feet, or just big enough for a thin mattress and a little maneuvering beside k. The rest of the bathhouse is mostly comprised of different areas for men to "cruise"--to check out the other bodies and decide which one to bring back to a room. These include a gym (complete with free weights, Nautilus equipment, and aerobic trainers), a sauna, Jacuzzi, and group showers. Elsewhere, gay porn videos play to help men get aroused. For those who like to watch, be watched, or have group sex, there are also orgy areas, including a fantasy "jail," a picnic table for men to lean over when receiving anal sex, and "slings" into which men can strap themselves to expose their anus for anyone who happens by.

Bathhouses are wholly designed to facilitate anonymous sex--sex as a purely physical act, without context, past, or future. But the most anonymous areas of all are the "maze" and the "glory hole" booths. The maze is completely black, a tangle of paths and dead ends defined by vertical sheets of darkly painted plywood where men grope until they find one or more receptive bodies. The booths are paired and separated by plywood through which fist-sized holes have been cut at hip level. Men manage to have not just oral but also anal sex through these holes, guaranteeing that each hasn't the slightest idea with whom he is copulating. With the act of sex stripped to its essential physical steps, it is easy--and quite common--for patrons to have sexual contact with several men in a single visit.

Even beyond their physical designs, baths influence their patrons' behavior by maintaining certain clear-cut rules. "Most bathhouse cruising is non-verbal," advises a bathhouse Web site, which also makes it clear that "most of the time you don't learn each other's names" "Conversations in the orgy rooms should be kept to a minimum," advises another site. Also, "It is considered embarrassing to make it with someone you already know," and "It is uncommon to use condoms during oral sex." One bathhouse Web site even has its own Miss Manners, a column called "Ask Towel Boy" in which a veteran gives practical answers to such questions as "Is it a social misdeed to walk around nude all the time?" and "How do I refuse someone's advances without offending them?"

Although they are small in number, bathhouses have an impressive reach. One survey found only about 80 bathhouses and sex clubs in the entire United States. But a recent study of gay men in major cities revealed that nearly one-third had visited such a place in the previous year. Furthermore, surveys of men who frequent baths confirm what their surroundings encourage: On average, bathhouse patrons have had sex with more than 30 different men in the previous six months. Baths can serve thousands of men per week, and major gay gatherings such as New Orleans' "Decadence" and Mardi Gras attract men from all over the country. Not surprisingly, this makes them critical hotspots for the spread of sexually transmitted diseases, including HIV.

Bathhouses like the one I visited became infamous for their role in spreading the AIDS virus in the 1980s. The. disease raced through gay men in magnet cities like San Francisco, Los Angeles, and New York because it was so easily spread through the dense sexual networks centered in the baths. Many bathhouses were shut down at the time in an effort to contain the epidemic. But while the number of bathhouses is lower now than in the 1980s, most major U.S. cities still have at least one, and the behavior of customers has grown steadily riskier in recent years, to the point where there is now an explosion of syphilis among bathhouse clientele. When I was medical director for the HIV and STD program at the Louisiana Office of Public Health, part of my job was to keep an eye open for such outbreaks, since syphilis--which causes open sores on the genitalia and makes it easier to transmit disease--often presages an outbreak of HIV. If public health officials don't respond effectively, the current syphilis outbreak could cause HIV to again spread through communities like wildfire. Today, more than two decades after the start of the AIDS epidemic and 15 years after public health officials and bathhouse owners first clashed over the problem, it is once again time to take a hard look at the evidence and either radically change the way they do business or shut them down altogether.

Sex in the City

The last time public health officials worried about syphilis outbreaks among gay men was in the late 1970s and early 1980s, when bathhouses were in their prime. Syphilis rates hit a decade-long peak during the unfolding tragedy of the then-mysterious AIDS epidemic in 1983. At the time, a French-Canadian flight attendant named Gaetan Dugas was a loyal bathhouse customer. According to Randy Shilts, the reporter who wrote the history of the early AIDS epidemic, And the Band Played On, Dugas was blond, handsome, and ravenous for partners. His job took him to cities throughout North America, where, by his own claim, he had sex with 250 men a year for at least three years. Later, when he became one of the first men diagnosed with the "gay cancer" of Kaposi's sarcoma, William Darrow, a disease control specialist for the Centers for Disease Control and Prevention, managed to link Dugas to 40 of the first 248 AIDS cases diagnosed in this country in 10 different cities. Although Dugas is infamous for his role in spreading HIV, AIDS researchers believe that if he hadn't, many others could have taken his place, This is because of the way gay men were having sex at the time. Bathhouses, which had been small, seedy, and advertised only by word of mouth in the 1950s and early 1960s, flourished to become a central part of urban gay life in the 1970s. Statistics are hard to come by, but one report claims that more than 50 percent of gay men in major cities visited the baths; 20 percent described their visits as "somewhat" or "very" frequent.

Between 1979 and 1984, with syphilis peaking and bathhouses serving thousands of men a week, HIV tore through the gay population in magnet cities like San Francisco and New York. Reconstructions of the epidemic estimate that close to half of gay men in these cities--and between 270,000 and 490,000 nationwide--became infected in just these few years. As gay men, public health officials, and finally the nation began to comprehend the true horror of the AIDS epidemic, a few began to call for the bathhouses to be shut down. San Francisco mayor Dianne Feinstein first raised the issue with health director Mervyn Silverman in 1982, but, under pressure from gay groups, Silverman initially balked. By late 1984, with the number of AIDS cases in San Francisco reaching about 750, reports by private detectives outlining the continuing high-risk sex in bathhouses, and a survey showing that 10 percent of gay men in San Francisco were still visiting the baths, Silverman ordered them shut down. The following year, the number of gay men newly infected with HIV declined dramatically. The public closure of San Francisco's baths is what many people remember of those days, but the story doesn't end there. The bathhouses sued the city, and a California Superior Court judge allowed them to reopen, provided they took the doors off the private rooms and booths, so men could be monitored, and hired staff to roam through the baths, kicking out any men engaged in "unsafe sexual practices."

The bathhouse closures in San Francisco put political pressure on other AIDS hotspots to do the same. By late 1985, New York allowed local officials to close establishments in which sex was taking place. New York City mayor Ed Koch declared the rules to be "inadequate" and unenforceable, but nonetheless pushed for a court order and closed several bathhouses. The Los Angeles Board of Supervisors passed regulations in 1986 requiring bathhouse owners to police their establishments and eject anyone engaging in high-risk sex. As stories of bathhouse behavior spread, similar rules were passed in other cities.

As the public saw the government respond to the AIDS epidemic and shut down baths and as the HIV epidemic seemed to slow among gay men, however, this vigilance diminished. Battles continued out of the public eye, and many baths managed to stay open or have since reopened, with little oversight from health departments. In San Francisco, the baths were replaced by "sex clubs"--essentially bathhouses without enclosed rooms, in keeping with the judge's order. In New York, four bathhouses never closed. The city began regular inspections, but decided to limit its oversight to sex taking place in plain sight. "We've demonstrated our concern," State Health Commissioner David Axelrod told The New York Times in 1987, adding that he did not "believe it is the responsibility of the government to enter into someone's home. And we view the doors of the private rooms the same way." Likewise, in other dries, the private rooms remained and government officials gave up trying to close them. When government oversight relaxed, not only did the baths remain, but barely a year after the highly publicized closings, their popularity rose once again. By 1987, business had "gone up 20 to 25 percent," said the owner of a New York City bathhouse.

Violating the "Code"

Over the past 15 years, bathhouses have continued to operate mostly out of view of the general public, even though they are widely known to gay men. During the mid-1980s, as gay men watched their friends go from healthy to dead in weeks, the "condom code" took over, and even in the baths condom use became the expected norm. Since then, though, with HIV-fighting drug cocktails keeping HIV-infected men not just alive, but also looking and feeling healthy, the AIDS epidemic has lost the profound emotional impact it once had, and the number of sexually active infected men has skyrocketed. Throughout the 1990s gay men increasingly abandoned-condoms. As "bare-backing" has become more frequent in the baths, they have again become focal points for the spread of various sexually transmitted diseases. The most convincing (and alarming) evidence of this return of risky sexual behavior among gays is the resurgence of syphilis. After a national epidemic related to crack and prostitution in the late 1980s, rates of syphilis had dwindled low enough that in the late 1990s the CDC announced a plan to eradicate the disease altogether. But in 1999 and 2000, clusters of syphilis in gay men cropped up in several cities where the AIDS epidemic first took off. In New York, Los Angeles, and San Francisco, the number of cases of syphilis in homosexual men approximately doubled every year from 1998 through 2001, and it looks like they will double again this year.

In its primary and secondary stages, syphilis induces raw, oozing genital sores in which the syphilis spirochetes multiply, eager to hitch a ride on the next sex partner. These sores cause breaks in the protective layer of skin, which exposes a person's blood and immune cells to his partner's, thus throwing open the door to HIV. Experts believe that syphilis may increase the probability that HIV transmission will occur in a single sex act by a factor of anywhere from 10 to 50. While the number of new syphilis cases in gay men may seem small--in 2001 there were between 100 and 150 cases each in New York, Los Angeles, and San Francisco--the combined total in these cities alone is more than the 251 persons who had been reported to CDC as having AIDS in February 1982, by which time the CDC had convened a national task force to track the emergency. Perhaps most disturbing, about half of the men infected with syphilis are also infected with HIV--a pattern that not only shows how often HIV-positive men are having unprotected sex today, but also all but guarantees that syphilis will have a huge impact on how quickly HIV is spread.

The syphilis outbreaks seem to be centered in the baths. Cities that have compiled data on the issue found that infected men like one-time pick-up sex, a practice that ensures that their partner's name remains as foreign to them as their HIV status. In California, about 25 percent of men with syphilis had had sex in baths or clubs during the time in which they were likely infected; in Seattle the number was 46 percent. In several cities, the CDC is investigating the baths' role in the epidemic. And while the results are not yet public, local health officials whom I spoke with in Los Angeles and New York were emphatic that the baths and sex clubs were critically important to the epidemics.

To health professionals such as me, syphilis outbreaks in bathhouses are a nightmare. History shows that once syphilis gets rolling, it can quickly reach epidemic proportions. Going by the number of homosexual men acquiring syphilis last year and the fact that infections are doubling every year, by 2004 there could be 12,000 cases a year--enough to qualify as the next epidemic wave of syphilis in America. With it will also come the next wave of HIV: These new syphilis cases could increase the number of gay men newly infected by HIV by thousands per year. The potential of such leaps in the number of HIV infections two decades after we've learned how to prevent them ought to scare us into action.

Risky Business

Bathhouses are not just a haven for risky sex; in many ways they promote it. It is clear that many gay men find anonymous sex appealing, and that as long as there is a place where no-strings-attached sex with strangers is sanctioned, supported, and encouraged, plenty of them will go. But once men arrive at baths for sex, the surroundings can strongly influence how they have it.

David McKirnan, a psychologist at the University of Illinois, points out that condom use during sex "is an externally imposed diet that may not require a very powerful external stimulus to break down" In other words, the fantasy environment and sexual smorgasbord of a bathhouse are more than enough of a stimulus for many men to forego condoms. McKirnan argues that "the physical features of many sexual situations may facilitate cognitive disengagement, e.g., bars or clubs that are extremely loud, poorly lit, or that present erotic visual stimulation, or sexual settings that stress anonymity." So the very features of a bathhouse that make it easy to have sex also make it easier to have dangerous sex.

The best way--and perhaps the only way--to prevent a big new epidemic of HIV in gay men is to close these bathhouses for good. Yet, suggest this obvious solution and you will hear a litany of reasons from both gay men and many public health officials about why it can't or shouldn't be done.

The most common refrain is that if we close bathhouses, patrons will simply go someplace else for pickup sex, and since other venues are less likely to offer condoms and reminders about safe sex, the men are likely to take even more risks. I don't buy this argument for several reasons. First, while it's true that many places besides bathhouses and sex clubs offer anonymous sex ("back rooms" of many gay bars, adult bookstores, public bathrooms, or secluded spots in municipal parks, and even temporary bathhouse-like scenes in apartments organized over the Internet), the assumption that men deprived of formal bathhouses will necessarily go elsewhere for pick-up sex is suspect. It is what Shilts derided as the "sex maniac" defense of the baths: Any gay man who derives pleasure from the bathhouse orgy scene must be so crazed that he is not influenced by the world around him.

There is much evidence to suggest that this is not so. The stories written by bath patrons on Web sites indicate that some--perhaps many--men visit baths somewhat tentatively, experimenting in havens for anonymous sex. "My friends talked me into some funny stuff to remove my inhibitions on the first time visit," wrote one, who apparently got very high or very comfortable, because later "I must have sucked about 30 guys through the glory hole." Another explained, "I consider myself straight but curious ... [O]ne afternoon when my wife was at work and I had the day off ... I got an odd urge to check on the gay scene, thinking it was just a curiosity." He then described how he was the anal receptive partner for four men in the space of just a few minutes. If these men had been forced to find anonymous partners in public bathrooms or the bushes of a city park, they might have decided to stay home. Daniel Wohlfeiler, an HIV prevention researcher at the University of California at San Francisco, who is as familiar with the baths as any expert, told me he is convinced that if the baths were closed, "a bunch" of men would not go elsewhere. The demand for anonymous sex is "somewhat determined by the supply" of places where men can get it.

Second, the argument that bathhouse sex is safer than sex elsewhere is just plain wrong. While bathhouses don't sell alcohol, many men drink at bars or take drugs elsewhere before visiting them. Given the level of intoxication of bath patrons, any intentions to have safe sex are often lost in a fog of drugs. Everyone I spoke to agreed that men in baths virtually never use condoms during oral sex. Even during the far-riskier practice of anal sex, men frequently "bareback." Twenty-one percent of those surveyed at a Portland bathhouse who had had anal sex did so without a condom.

Third, even if men in the baths went elsewhere for sex, it's unlikely that they would have the same type of sex. Physical and social settings have a great deal of influence on what actually occurs. It is more complicated to have anal sex (with or without a condom) in a public restroom or behind a park bush, where sex is rushed for fear of getting caught, than it is in a bathhouse. Consequently, these men are more likely to have oral sex, which is less likely to spread HW. In a broad survey of behavior in four large cities, 34 percent of bathhouse patrons had had unprotected anal sex, versus only 20 percent in other cruising spots. Perhaps even more important, it would be nearly impossible for men to have multiple partners in a single park encounter--but in bathhouses, it's routine. History also argues that closing baths does indeed lower risky behavior. After San Francisco closed its baths in 1984, the number of men who had multiple partners or engaged in risky sex plummeted by about 60 percent.

But perhaps most important is the epidemiological effect that baths have on spreading sexually transmitted diseases. Most people who acquire STDs do not spread them to others, either because they have only a single sex partner (who infected them) during the period in which they're infectious, or because they use condoms when swaying from their partner. Conversely, the relatively few people who change partners very frequently--such as bathhouse visitors--can infect scores. Experts who develop mathematical models of STD epidemics call these people "core transmitters." They are, as one writer put it, the people who "keep the critical mass critical." If an infected core transmitter comes into contact with men who are unlikely to spread the disease--even a large number of them--he will infect many, but won't trigger an epidemic. If, on the other hand, a core won't trgger has sex with just a few other core transmitters, something akin to a nuclear chain reaction takes place, causing the disease to explode in a population. One need look no further than the example of America's most famous core transmitter, bathhouse enthusiast Gaetan Dugas.

Thus the speed, at which HIV travels through a population is determined in large part by who is having sex with whom. The best way to spark an epidemic is to create opportunities for core transmitters to have sex with each other. Bathhouses--magnets for core transmitters designed precisely for one-time sex with multiple partners--do just that.

Power to the People?

When I told several colleagues at a recent national STD meeting that I thought the resurgence of gay men having anonymous sex probably spelled the end of our hopes of eliminating syphilis and a comeback of the AIDS epidemic, all agreed. But rather than jump into discussions about how to respond, most seemed to fall into despair.

This stems partly from a pervasive feeling of powerlessness. Dr. Peter Kerndt, the director for the STD Program at the Los Angeles County Department of Health Services, told me, "If the gay community won't protect itself, we can't protect them." I've heard variations on this sentiment from many public health professionals, but it continues to puzzle me. Clearly, the gay community as a whole is supportive of safe sex, since the majority of men either don't frequent baths or use condoms when they do. It is unclear to me what the "gay community" can do about the minority of men who continue having high-risk sex. Without an organizing structure, designated leaders, or an enforcement arm, it is they who are powerless. Bathhouses are, after all, forprofit businesses that trade in anonymous sex and risk losing money if they stop providing an experience (unsafe sex) that appeals to even a minority of customers; they simply can't be trusted to police themselves.

Government, on the other hand, is supposed to have the power to prevent a few people or businesses from threatening the broader public health. The despair among government officials like my colleagues stems from a structure and culture developed during the AIDS epidemic that is based on inclusion and cooperation rather than enforcement. This government culture seems to have grown as a response to AIDS activism in the 1980s, which itself was a response to the lethargy government agencies initially displayed toward this plague of historic proportions. AIDS activism, which embraced such tactics as haranguing experts at scientific meetings, blockading FDA headquarters, and pressuring politicians to cough up public money for prevention and treatment, effectively prodded government agencies into taking steps to curb the epidemic that otherwise might never have happened. But in an era when politicians of all stripes argued that all government was bad, it also made agencies adopt a very defensive posture. To deflect criticism, public health agencies began accepting on faith that all of their own judgments were faulty, that all opponents had legitimate positions, and that all interested people (no matter how self-interested) should be appeased by including them in decision-making.

Public health agencies, operating HIV prevention programs based in large part on grants from the CDC, are required by congressional mandate to spend these funds under the direction of a committee "representing the community" and co-chaired by a community member. In most cases this means the majority of committee members are gay men, former drug users, and others who work with them, most of whom vigorously protect the right of high-risk people to do what they want to do. As beneficial as this system may be in building mutual trust, it prohibits health departments from taking virtually any action to prevent AIDS that contains even the barest whiff of enforcement. Inclusion can be a good thing in planning public policy--but it can also be taken too far, as when it gives people veto power that imperils public health. Imagine if the local health department couldn't shut down a restaurant serving salmonella without first securing the permission of restaurant owners.

Because of this structure and the culture surrounding it, little enforcement actually occurs in the baths around the country. In San Francisco, health officials inspect sex clubs about twice a month to make sure that safe-sex posters are displayed and condoms are available; they also write vaguely threatening letters to clubs named by patients with syphilis as permitting unprotected sex. New York takes almost the opposite approach; the city sends inspectors to gay bars and other sites to make sure customers are not having sex in open areas, and will shut them down if they are; but it ignores baths where sex takes place behind closed doors. To my knowledge, baths in other cities are unfettered by health inspectors.

This lackluster state of enforcement is the final remnant of the bathhouse battles of the 1980s: Elected officials delegated decision-making to the courts, which delegated it to health departments, which educated owners about safe sex and then delegated enforcement to them. Bathhouse owners, in turn, delegated responsibility to their patrons, who stopped using condoms and once again started spreading HIV and syphilis.

When I suggested to several colleagues at the STD meeting that the baths should be closed, many (though not all) agreed. But even those who agreed seemed to recoil at the idea of actually doing it. The reason is partly the past success of our cooperative approach to HIV prevention. But I can't help wondering if a part of the reason is also fear--fear ,of being shouted down at meetings by activists, or of being politically undercut or fired by elected officials, some of whom may receive campaign donations from bathhouse owners and gay advocacy groups. The risks don't stop there, though. Dr. Jeffrey Klausner, the director of STD Prevention and Control Services in San Francisco, was quoted in a Washington Monthly story last November ("When Rubbers Hit the Road," by Andrew Webb) as being in favor of closing sex clubs; he received repeated death threats, as did his family. During the bathhouse battles of 1984, Shilts writes, San Francisco health director Mervyn Silverman received so many death threats that he started wearing a bulletproof vest.

Ban the Baths

Most baths do take steps to encourage condom use. They have reminder posters on the walls, and bowls of condoms placed throughout the establishment. Some offer regular HIV testing. But prevention usually stops there. Many baths do not even have signs telling men that sex without condoms is forbidden, much less eject them if rules are violated. Because of the cooperative model for containing AIDS that arose in the 1980s and still reigns, public health agencies are at a tremendous disadvantage: Even those that recognize the danger of bathhouses can only try various modes of persuasion.

To prevent the spread of HIV, most agencies fund community-based AIDS service organizations that conduct "outreach to" (not "inspections of") bathhouses, an approach not of enforcement but supplication. As Wohlfeiler put it, public health officials are usually grateful when owners are "magnanimous" enough to let them in the door. This encouragement-without-enforcement approach seemed to work in the late 1980s, when gay men terrified of the epidemic adopted condoms pretty faithfully. But the syphilis outbreaks now make it clear that we need a new strategy. With the activists and the courts potentially protecting the status quo in bathhouses, it's worth considering what steps could be taken short of outfight closure. One possibility is for dries nationwide to couple San Francisco's ban on sex in closed-door rooms with serious enforcement of condom use, so that public health inspectors can catch--and stop--risky behavior. There is evidence to suggest that a strict enforcement policy could work. Buzz Bense, the owner of a San Francisco sex club called Club Eros, requires customers to read and sign an agreement stipulating that they will follow the rules, which include using condoms. Club goers have sex in open, well-lit rooms, observed by staff members who circulate at regular intervals. Those caught having anal sex without condoms are kicked out; repeat offenders lose their membership. Bense says that customers accept these rules (he throws out fewer than five a month) and even appreciate them, since they no longer have to negotiate condom use. But to reliably prevent HIV spread, even strict enforcement by club owners would require an additional layer of government enforcement.

Until recently, the HIV epidemic seemed to be waning in all major groups: gay men, IV drug users, and high-risk heterosexuals. But the syphilis outbreaks not only tell us that our hopes of eliminating this disease with the next decade are gone, but also confirm predictions that we will see a second wave of HIV infection in gay men. If we want to keep this second wave at bay we must make dramatic changes in how we deal with the baths. Unless we are willing to hire plenty of full-time condom inspectors for the long haul--a strategy that history tells us may fail--we ought to finish the job we started in the 1980s and close the baths for good.

TOM FARLEY is a professor at the Tulane University School of Public Health and Tropical Medicine.