Male Sex Work in a Small U.S. City: HIV Risk, Substance Use, and Mental Health.

Male Sex Work in a Small U.S. City: HIV Risk, Substance Use, and Mental Health, Michael D. Smith, Samantha Hetrick, Joanna Marino, Katherine McMonegal, and Katherine Meyer, Susquehanna University; David W. Seal, Center for AIDS Intervention Research

We used qualitative interviews to collect psychosocial and sexual behavior information from 30 male commercial sex workers (MCSW; aged 18-35, mean = 22.4 years) working for an escort agency in a rural mid-Atlantic U.S. city (population less than 50,000). 80% self-identified as homosexual/bisexual. Participants reported six clients per month on average, 99.5% of whom were male. Sexual activity occurred about two thirds of the time. MCSW's primary HIV risk with clients was from oral sex. Most MCSW avoided anal sex with clients, especially if not well-known, due to HIV infection concerns and a sense of emotional violation. Condoms were consistently used for both receptive and insertive anal sex (mean = 99%). During unprotected anal sex, participants avoided semen exchange. Condoms were used for oral sex about 10% of the time, and rates of semen exchange were low (0% from clients; 11% from participants). Condom use rates were lower (50% for male anal sex partners; 35% for female vaginal sex partners) and semen exchange rates higher with non-client partners. Most MCSW obtained regular HIV tests. 29 were HIV-negative, and less than 15% had a history of STIs. Nearly all participants drank several alcoholic beverages weekly, and most binge drank. About two thirds of participants used other substances weekly. About 20% of MCSW said they had a drug or alcohol problem, but none ever received professional treatment. In the past month, slightly less than one third of MCSW used substances when having sex with clients. Two thirds used substances during sex with non-clients. However, substance use during sex was not related to increased HIV-risk behavior. 70% of the participants had clinical levels of psychiatric distress, most often indicative of mood or substance use disorders. Psychiatric distress was related to overall substance use but was not related to HIV-risk behavior or substance use during sex.