The economy of risk and respect: accounts by Puerto Rican sex workers of HIV risk taking.

The HIV pandemic has forced us to think of risk in a new way. Knowledge and education about HIV risks alone have largely failed to change sexual and drug-using behaviors among those at the highest risk for infection (Kelly & Murphy, 1991; Khalsa & Kowalewski, 1994; Tice, 1992; Biemiller, 1991). We have begun to ask how "high risk" sexual and drug-use behaviors, often construed as a matter of individual choice, are socially produced (Holland & Ramazanoglu, 1990; MacPhail & Campbell, 1999). Behavior is enabled by specific social circumstances. Acts which we think of as risky from one perspective may actually be seen as safe within other social contexts.

Since the development of the HIV pandemic, many studies have examined high risk drug-use and sexual behavior within an individualist paradigm, framing HIV risk behavior as the result of either poor information or illogical choices with regard to health, and have sought to attribute HIV risk behaviors to individual characteristics of their practitioners (Bourgois, 1999; MacPhail & Campbell, 1999). Alternately, a growing body of literature has focused on the structural factors--such as power inequalities along the lines of gender, social class, income, race, or ethnicity--which predetermine the HIV infection rates experienced by members of groups at elevated risk, such as Latinas and sex workers, and which place constraints on their choices with regard to self-protective sexual and drug-use behavior (Bourgois and Dunlap, 1993; Farmer, Connors, & Simmons, 1996). Fewer studies have examined how these women navigate themselves within the context of their social universe, replete with competing risks and rewards on physical, economic, and moral planes (Rhodes, Stimson, & Quirk, 1996). Given that drug use is associated with higher risk sex exchanges among sex workers, understanding how drug-using sex workers in particular modify the hazards and social symbolism of their work and their addiction is of utmost importance (De Graaf, Vanwesenbeek, Vanzessen, Straver, & Visser, 1995; Estebanez, Fitch, & Najera 1993; Pyett & Warr, 1997). This paper reviewed interviews with female, drug-dependent sex workers recruited from neighborhoods of high volume commercial sex work in urban Puerto Rico. In the process, we attempted to understand how sexual practices which are incomprehensible within an HIV-prevention perspective are actually rooted in a local cultural logic.

In our analysis of these narratives we drew upon the theoretical framework of structured action (Dunn, 1998; Messerschmidt, 1997). Structured action posits that social categories such as race or ethnicity, gender or class are achieved through social interaction. In this context, people draw upon their daily experiences and understandings to provide meaning to their social life (Simmel, 1950). Theorists of structured action have applied this concept to the narratives of structurally marginalized people, such as gang members and women, to show how they adapt to their social circumstances and to explain their nonmainstream behavior as an attempt to parallel mainstream social norms (Dunn, 1998). At the same time, people operating from marginal social positions interpret their actions in nonmainstream ways, imbuing them with locally generated meanings (Messerschmidt, 1997). In this view, a narrator is "neither simply the product of her circumstances (a victim) nor the producer of her world (a powerful female) but, rather ... both" (Dunn, 1998, p. 479).

Puerto Rico is a commonwealth of the United States, meaning that it is subject to most federal regulations and subsidies. Puerto Ricans are U.S. citizens, although they do not vote in presidential elections nor do they have voting representatives in the U.S. Congress. Compared to the 50 United States, Puerto Rico is poor; in 1990, one half of all Puerto Rican families earned less than $10,000 a year, and 20% of eligible Puerto Ricans were unemployed (Chavez, 1998). In 1998, 57% of the population was below the poverty line (Latinamerica Press, 2001). Narcotics trade and use are also documented as wide-reaching problems for the island. Puerto Rico has been federally designated as a zone of high intensity drug traffic (Colombiani, 2001), and a recent household-based survey estimated that 5.6% of the population 15 to 64 years old is currently in need of substance abuse treatment (Colon et al., 1998). While little island-wide data on the extent of commercial sex work in Puerto Rico is available, studies of sex workers in Puerto Rico using street outreach methods found that the majority of those surveyed reported substance use and engaged in sex work for economic reasons (Alegria, Vera, Freeman, et al., 1994; Alegria, Vera, Rivera, et al., 1994; Burgos et al., 1999).

In this context of widespread poverty, substance abuse and related sexual behaviors have conspired to make HIV infection among the most important threats to the health of Puerto Ricans today. Over 14,000 cumulative cases of AIDS have been reported from the San Juan metropolitan region alone, and Puerto Rico has one of the three highest reported AIDS rates among women in the United States (CDC, 1999). Female gender, poverty, and drug use characterize those Puerto Ricans becoming HIV infected at the highest rates.

The women interviewed for this study were engaging in illicit drug use and commercial sex work during a period in which the government of Puerto Rico instituted a program of more aggressive narcotics arrests and stringent sentences. Our narrators were thus operating in the context of a heightened threat of arrest and incarceration for either narcotics possession or sex trade.

Common HIV risk factors for Latina women include drug use, male sexual partners who use drugs or have sex with men, and low levels of knowledge about HIV and AIDS (Alonso & Korek, 1989; Amaro, 1995; Corby, 1991; Gil, 1995). Injection drug use and smokeable cocaine (or crack) in particular are related to HIV transmission among Latinas, both through shared injection equipment and through sex-for-drugs-or-money exchanges. However, research delineating the institutional and individual factors contributing to drug use among Latinas is lacking, and drug use patterns vary significantly among ethnic subgroups (Alegria, 1998). Poverty, low levels of education, and poor access to medical care are also strongly associated with the risk of HIV and AIDS among Latinas (Simon, 1994; Suarez & Seifert, 1998). Finally, traditional gender roles that stigmatize female sexuality and Latina women's reluctance to discuss sexual practices with male partners are emphasized in the literature (Barkley & Salazar-Mosher, 1995; Deren et al., 1997; Flaskerud & Ruiz-Calvillo, 1991; Moore, Harrison, Kay, Deren, & Doll, 1995).

Latina sex workers in particular have been under-researched by scholars of HIV and AIDS. Psychological studies of sex workers in Puerto Rico have revealed the majority to be suffering from depressive symptoms (Alegria, Vera, Freeman, et al., 1994), suggesting that comorbid factors such as depression and addiction must be considered in interpreting their HIV risk behaviors, particularly given the frequency of histories of abuse and trauma among female sex workers and drug users (Fullilove, Lown, & Fullilove, 1992). Existing ethnographic studies of Latina sex workers indicate that their stigmatization creates extreme role conflicts. For example, Castaneda, Ortiz, Allen, Garcia, and Hernandez-Avila (1996) point to the double bind of the social schizophrenia faced by Mexican female sex workers, who must reconcile a dual female archetype of "mother-saint" and "traitor-prostitute" as they engage in sex work to support their families.

In other ways, however, Latin American cultural traits may be protective against HIV. Deren et al. (1997) compared cultural attitudes and behaviors bearing on HIV risk among female Puerto Rican sex workers in the U.S. with those of Dominican and Mexican sex workers in the U.S., and found that Puerto Ricans reported the highest rates of HIV sexual and drug using risk behaviors, as well as the highest levels of acculturation as reflected in language and place of birth. They concluded that traditional Hispanic family-centered values and supports were factors protective against HIV, including among sex workers. In contrast, in their comparison of sexual and drug-using practices of Puerto Rican and African American sex workers in Connecticut, Weeks, Grier, Romero-Daza, Puglisi-Vasquez, and Singer (1998) found little difference in the reported HIV risk behaviors of these two groups, and concluded that this pointed to "the overriding (and unifying) importance of their experiences with poverty, addiction and street prostitution as a means to support themselves" (p. 217). The literature on Latina sex workers who use crack cocaine in the U.S. has emphasized the influence of structural factors on their HIV risk behavior. Bourgois and Dunlap (1993) report that sex-for-crack exchanges occur within a dehumanizing context of violence in which women sell sex in desperation to obtain their drug of choice. These women rarely consider precautions against HIV, as the immediate goal of getting cocaine becomes more urgent than the preservation of their health in the long run.

Research on HIV in Latin America reveals that sex workers make complex distinctions between sexual relationships. For example, Kane's (1998) study of sex work in Belize shows that local women who work from bars do not define their sex-for-money exchanges as sex work because they want to avoid the stigma attached to prostitution. They define themselves as being in intimate relationships with their clients. Because condoms are associated with prostitution, they do not use condoms with these clients. On the other hand, foreign migrant women who work in bordellos have higher rates of condom use. They regard themselves as "border crossing professionals" who are able to "shed the stigma of sex work when they depart, crossing back into their lives with hard won financial reserves" (Kane, 1998, p. 69). Sex workers also use such distinctions in an attempt to minimize their exposure to HIV. In their ethnographic interviews with Puerto Rican and African American sex workers in Connecticut, Weeks et al. (1998) found that these women sought to minimize their risk of HIV by using their intuition about potential clients, seeking steady clients, limiting their repertoire of services to those perceived as less risky, and employing local concepts of general hygiene before and after sexual acts. Overall, then, the literature thus indicates that while sex workers try to protect themselves from HIV, they generally operate under social and economic circumstances which frustrate their efforts.

METHODS

Sample

The narratives analyzed in this paper were collected in 1995 as part of the "Drugs, HIV Infection and High Risk Behavior among Puerto Rican Sex Workers" project of the University of Puerto Rico School of Public Health. A purposive sample (Bernard, 1994) of 311 women between 18 and 34 years of age was recruited from low-income urban neighborhoods of visible drug traffic in the municipalities of Arecibo, Caguas, Catano, Bayamon, Manati, Mayagues, Ponce, Rio Piedras, Santurce, Vega Alta, and Vega Baja. By study design, half of the participants described themselves as current users of heroin or cocaine (frequency and quantity of use not specified in the initial screen), and all identified commercial sex work as a major source of income. Nearly 48% of the study participants identified the greater San Juan metropolitan region as their primary place of work. A basic demographic profile of the study participants is provided in Table 1, and their sex work histories are summarized in Table 2.

Procedure

Epidemiological technicians from the Puerto Rican Central Office for AIDS Affairs and Sexually Transmitted Disease (OCASET) made initial contacts with potential study participants through street outreach in neighborhoods selected for their known high volume of street sex work activities. They provided potential participants with HIV pretest counseling and referred them to a research supervisor who assigned each potential participant to 1 of 10 project interviewers. The overall response rate among those approached for participation was 96.5%. Spanish-speaking interviewers obtained informed and voluntary consent from those interested in participation and administered the survey instrument orally in private rooms of local public health clinics and mobile health service vans. A medical team of two nurses, a physician, and a medical technician gave participants a gynecological exam, treated participants for medical conditions found, collected hair and urine samples for drug testing, offered testing and counseling for STDs (including HIV, Hepatitis B and C, gonorrhea, and chlamydia), and referred participants to community-based service agencies as appropriate. Participants received $25 for their participation in the study and were given vitamins, clothes, and personal hygiene products as gifts.

All interviewers held bachelor's degrees and most were in postgraduate study in the social sciences. Interviewers were intensively trained in the administration of the instrument using role-play techniques and were given ongoing supervision and quality control by Ph.D.-level public health researchers from the University of Puerto Rico. These training techniques maximized inter-interviewer reliability, as did quality-control reviews of completed interviews and regular meetings of interviewers with supervisors.

The narratives analyzed in this paper were elicited in response to the open-ended question "Describe your experience with your last client from the time you encountered him until he left." This question was part of a 209-item survey instrument which asked about sources of income, physical and mental health status, family composition, social support, sex work practices, perception of HIV risk, condom use and other HIV-prevention strategies, drug-use practices, and drug treatment. Study participants were given as much time as they desired to answer survey questions. When asking the open-ended survey question reported on here, interviewers probed the participants about specific sexual practices, how they were requested and negotiated, who determined them, whether any practices were refused, where the practices were performed, how much time they spent with the client, how much and with what they were paid, how and where they were left after the encounter, what they did immediately after the encounter, and what they did with the money earned. Participants were also probed about use of condoms and other forms of protection, how protection was discussed, and who provided it. Interviewers reported on the informants' responses either in their own words (in first person) or paraphrased (in third person).

The first two authors of this paper read and coded all responses to trace recurring themes and to select particularly descriptive passages for in-depth analysis. The responses, all of which were written in Spanish, were translated into English and analyzed by the first author, who is fluent in Spanish, and the second author, a native of Puerto Rico. The third author, a native of Puerto Rico with over a decade of experience conducting research on the population targeted for this study, assisted in the analysis of responses.

RESULTS

A summary of responses to survey questions about perception of HIV risk and HIV prevention strategies is provided in Table 3 to contextualize the findings from the open-ended narratives described below.

The Landscape of Danger: Structure Constraining Action

As we might expect in this context, the women interviewed identified many hazards against which they must be vigilant in the course of their work on the streets: arrest, violence, a client's reneging on an agreed upon exchange, physical illness, withdrawal from narcotics, and material deprivation of themselves and their families. The constant threat of violence led women to recruit protection. One woman who met her last client, a regular, in a customary site, explained that the "muchachas del caserio" (sex workers from the housing project) all look out for one another, taking down license plate numbers and noting the amount of time that each worker is with a client. Other women relied on husbands, lovers, or relatives to protect them. The threat of violence on the job could easily turn into reality: Two of the women interviewed had experienced rape in their last encounter with a client. Another woman had been sodomized by a client against her wishes. The women interviewed thus made guarding against violence a priority, investing considerable energy into the social networks that act as their insurance. On this basis alone they demonstrated themselves to be deeply enmeshed in a web of obligation and dependence.

Even more ubiquitous than violence was the concern that a given client would not uphold his end of the exchange. Most women asked for their payment up front, before providing sexual services. Often their negotiations started while they were still in public view before walking or driving off with a client. Condom use was a point of negotiation and agreement for a few women; one woman clearly stated to her client that "they would not have relations if (condoms) were not used." Far more of those interviewed, however, were primarily concerned with the size of their payment and the specific sexual services to be provided in their negotiations. Having no legal recourse if their agreement was broken, these women were acutely aware that their position in the exchange was weak.

Perhaps for this reason, the women valued regular, known clients who could be trusted. A regular client was a "good" client; their exchange with regular clients was faster and easier because both parties knew what was expected. Condom use was sometimes part of the agreement: Certain clients were said to "always use" condoms and, in some cases, always bring them or put them on without being asked. In other cases, however, regulars did not use condoms. Several women mentioned that they did not have to use a condom with a client well known to them, explaining that "I know him," "He is a clean person," or "He is married." Condoms in this context symbolized mistrust; regular clients were only those with whom the women wanted to cultivate trust.

The women interviewed also juggled the constant threat of withdrawal from narcotics. They often started their workday with symptoms of withdrawal; many started their stories with "I was sick," or "I needed money" to "cure myself." Many sought out clients who paid them with drugs, or took drugs with their clients before engaging in sex with them. The pressure to obtain drugs and ward off withdrawal symptoms was a driving force in these women's negotiations. Drug use itself put the women at risk. As one woman said, "If you look desperate for a fix ... (the client) wants to use you."

Finally, these women worked under pressure to meet the basic material needs of their families and themselves. With money earned from clients, they fed and clothed their children, helped their parents, and maintained themselves. In this context, often their fear of HIV and AIDS seemed less immediate than the day-to-day survival of their families and themselves. As indicated in Table 3, the women interviewed were aware of the HIV risk that their drug use and sexual practices presented, as reflected in the reasons that they gave for their estimation of their chances of having HIV (e.g., sex without condoms, sharing needles or injection equipment). Yet, HIV-AIDS was, for the majority, not perceived as the most important risk that they faced in their daily lives, but rather one risk among others such as murder, rape, overdose, or other diseases (see Table 3: How does this danger compare with the risk of infecting or reinfecting yourself with the virus that causes AIDS?).

The Ecology of Respect: Action Within Constraints

"He pays my rent and when I am with him I feel all right. With him I use condoms." In addition to immediate risks to their health, the women interviewed discussed more long-term aspects of their survival, both material and emotional. A recurrent theme in these women's stories was their interpersonal relationship with their clients. They cultivated particular types of client relationships depending on their emotional tenor, and negotiated condom use, as well as other behaviors, within this context. They described feelings of attraction, affection, detachment, or anger toward different clients, and described treatment from clients which ranged from protective to business-like to severely abusive. For example, one woman's conversation with her client consisted only of "he asked me how much I charged, I told him $20, he told me $15 and I told him yes." Another woman said she was "ditched at the beach" and had to walk back to the city after being told to "take her clothes off" and engage in intercourse. Yet other clients treated women in more respectful ways. One woman recounted the following:

   This guy approached me and told me that he was from my hometown. I did not
   recognize him. He told me he came because he heard I was working around
   this area. He said he wanted to be with me. I asked him how could it be
   possible that he came to see me when there were so many other pretty girls.
   He told me that he preferred heavyset girls and that he would like to date
   me some day.

Most of the exchanges that these women described fell into one of two styles of interaction with clients: that of detached and professional or that of emotionally intimate. These styles implied differing social roles that the women interviewed were performing with their clients, and therefore differences in the self-image that the women wished to create for themselves in the process. Styles of recruitment and negotiation with clients ranged from propositioning strangers on street corners or in bars to calling on "a friend" in his home when in need of money. Those women recruiting on the streets described their exchange as purely rational and economic, involving explicit haggling over the services to be provided and the price to be charged for each. Parties in the exchange engaged in little conversation, spent minimal time together outside of the sexual act, and preserved a sense of anonymity by providing no personal information about themselves in the course of the exchange. In addition, almost no women describing this type of interchange with their last client said they took drugs in the company of the client.

In contrast, other women related to their last client in a more personal way: Some clients were described as "friends." Others were clients that women found pleasant or "amiable," and with whom the woman might spend the night, have a long conversation, watch a movie, share drinks in a bar, or share drugs at home or in a hotel room. These clients were usually described as "regulars" with whom a woman had an understanding regarding preferred sex practices and the payment that the woman could expect to receive; explicit negotiation over the terms of the exchange was rare. These clients sometimes gave "tips" to women or "gifts" for their children in a show of good will. Although some women met regular clients at public places such as street corners or bars, often they met in their homes. Several women with this personal type of relationship with their clients said they called their clients at home when they needed money, initiating the exchange themselves. As one woman said, "He's always good with me, he told me to call whenever I want." One woman said that her client was jealous when he saw her soliciting other men, suggesting that he wanted her fidelity. Illustrating the extreme of this more intimate, personal style of relationship with clients was the story of a woman who cried and told her problems to her client, who "(gave) me advice because he is 50 years old." He advised her to give up drugs and enter treatment, offering to help her with the bills. He told her that he "felt as if he was in love and that it wasn't just sex." This woman's story demonstrates blurring of the distinction between the role of client and that of (unpaid) lover that is possible in the course of the sex work. Her relationship with her client clearly met many needs beyond her immediate material ones, as she asked for emotional support and was offered help in making significant changes in her life circumstances.

The divergent strategies of professionalism and intimacy were also evident in the profile of a good client given by different women. Many women interviewed expressed satisfaction with a client who simply did as agreed in the exchange. Other women mentioned understanding and empathy among the qualities of a good client; as one woman whose client (a regular) took her out to eat and bought her son food and pampers said, "They're not all bad, they have pity and they understand." In contrast, another woman expressed displeasure with a client who treated her as if "I was only his merchandise--an object." Relationships with clients, then, must be seen as both material and social. The quality of these relationships has implications for both the material security of the sex workers and their experience of their daily lives as meaningful. Positive relationships with clients sometimes facilitated condom use; on the other hand, some women felt that condoms threatened the very client relationships that they valued and found safe.

"I did not use condoms, that boy was very healthy." The women interviewed also distinguished some clients on the basis of their being "nice," "clean," and unpolluted, and therefore unlikely to contaminate them with HIV. They rarely used condoms with such clients: "We did not use any type of protection. He is nice, he treats me well"; "He invited her to his house (she already knew him). She took a shower and did it without a condom because he is a clean person"; "He looked fine so I did it without a condom." Those interviewed evaluate the "cleanliness" of their clients by using information they gathered through interactions with them. For example, they associated cleanliness with the marital status, youthfulness, and attractiveness of their clients.

The marital status of the client seemed to be a trait that women held in high status and perceived as a shield against HIV infection (e.g., "I didn't use a condom: he is married"; "He told me he was already old and that he had sex with his wife the night before"; "He did not wear a condom because he is clean, I know him, he is married."). In other accounts the women determined whether a client was polluted based on how he looked. Youth and physical attractiveness were desirable in clients and associated with good health; the women interviewed tended not to use condoms with young and attractive clients. For example, one participant said,

   When I looked at him he was a very cute boy, about 19 years old. I told him
   he could afford a blow job for $15. Everything lasted about 45 minutes. I
   did not use condoms, that boy was very healthy.

This logic of dirty versus clean overlapped with the bipolar negotiation styles of professionalism versus intimacy in sexual exchanges. Women with an instrumental, impersonal style of interaction with less pleasant or "dirty" clients often circumscribed their services. They refused certain acts, usually anal sex and in some instances oral sex. They also reported spending shorter amounts of time with these clients, as little as 10 minutes, while those describing a more personal, amiable relationship with a regular client often spent a full day or night with him.

The two concepts of being clean and knowing (being on friendly terms with) a client seem to be congruous with and lead to forgoing condom use with a client. Consistently the narrators extended trust to clients who were perceived as known or clean. As a sign of respect or trust, these clients were allowed to pay after sex, or were not required to participate in explicit negotiation around services and pay.

"My son will never go hungry. I do what needs to be done." Women also justified their sex exchanges by drawing on metaphors of motherhood. They framed their actions in ways that asserted their status as responsible mothers: "With the money I bought $50 in drugs. The rest I used for my children"; "Sometimes one does not want to do it (prostitution), and for my son I will do anything--if I have to give my life I'll do it"; "With the money I bought a box of Pampers for my son and with the rest I bought drugs." When these women spoke about the needs of their children, they not only described objective economic needs. They also constructed an explanation for the HIV risks they take which was congruent with mainstream gender roles for women. Consider these two examples:

   They did not use protection, no one brought condoms or mentioned protection
   ... He treated her well ... She has friends who provide protection ... she
   bought diapers and baby food for the baby.

   They did not use protection, no condoms were used. No one mentioned using
   protection ... when they finished they showered, talked, smoked marijuana,
   and used cocaine ... the money she used for her daughter's graduation
   expenses.

These women described taking concrete actions to provide for the material needs of their children, and in so doing implied that fulfilling their roles as mothers is a priority to them and that motherhood is central to their to their self-image.

DISCUSSION

Despite the stigmatization of addicted female sex workers in the heavily Catholic culture of Puerto Rico, representing those women who deviate the furthest from the feminine ideal, these women draw in different ways upon mainstream images of feminine fidelity and dependency in their relationships with clients. Although engaged in behavior labeled immoral by the greater Puerto Rican society, these female sex workers indicate that they operate with a finely grained moral system of respectability that parallels that of the society which stigmatizes them. Many of them still conform to the gender ideals of Puerto Rican society by cultivating intimacy and trust with male clients, by prioritizing their identity and duties as mothers, or simply by maintaining distinctions between clean and dirty sex or clean and dirty clients.

Drug use and sex with multiple partners are behaviors that are strongly sanctioned in women (Inciardi, 1993). The women described here justify their behavior and their use of the money they earn in ways that may be consciously designed to parallel mainstream societal norms. Motherhood is a powerful metaphor because it is central to esteemed ideals of womanhood, particularly among Latinos (Comas-Diaz, 1987). Stevens (1973) coined the term marianismo to describe what he saw as the Latin American cultural framing of ideal femininity on the model of the Virgin Mary. This model emphasizes sexual naivete, self-sacrifice as a mother and suffering for the good of the family, and confinement to the domestic sphere of home and childrearing, leaving the public sphere of the streets to men. In Steven's classic formulation, women earn respect, moral authority, and influence within the domestic sphere to the extent that they conform to the marianismo ideal. Studies of Latino gender roles and HIV risk have continued to draw on Steven's formulation to explain the sexual subservience of Latina women (Mayo & Resnick, 1996; Wood & Price, 1997). Other researchers have challenged Steven's premise that the subservience of Latinas to their male partners is primarily a strategy for moral elevation, and instead have pointed to the real economic and power imbalance in their relationships with men which require submission for survival (Ehlers, 1991). Yet, our findings resonate with those of others who report that among socially and economically marginalized Latina women engaging in illicit drug use and sex work, the cultural valorization of motherhood leads to a strategy of identity management based on motherhood which is enmeshed with but not exclusively derivative from economic concerns. The women quoted here describe heroic efforts to provide for their children, despite severe poverty and/or addiction and at great cost to themselves, rather than allow other people or agencies to take over that role. Studies of U.S. mainland Puerto Rican women in treatment for substance abuse have also pointed to the ways in which the Latino cultural ideal of motherhood is embraced and used as a grounding identity and marker of treatment success by women, even as they struggle against the wider society's characterization of them as "bad mothers" (Hardesty & Black, 1999). While these authors emphasize the health-promoting uses of a discourse of motherhood, in the case of the women interviewed in our study, their attempt to fulfill their mothering responsibilities despite economic deprivation and addiction is also a real force propelling them toward HIV risk behavior.

Just as sex workers in other studies of HIV risk report that they distinguish work sex from nonwork sex by forgoing condoms with unpaid, intimate partners (Kane, 1998; Waddel, 1996), the women in this study may have been using condoms to distinguish "high risk" from "low risk" clients. In fact, in their study of Dutch male sex workers, De Graaf and Vanwesenbeeck (1994) found this type of distinction between trusted, steady, or sexually attractive clients and newer, high risk, or undesirable clients central to the workers' decisions to use condoms or assent to receptive anal intercourse. In their study of Australian male sex workers, Browne and Minichiello (1995) also found that sex workers categorized their clients and determined which sexual practices they would engage in based on these categories. These findings parallel the ways in which women participating in this study define certain clients as healthy, clean, or trusted, and therefore forgo condoms or decide to use drugs with these clients.

In addition, sharing drugs with a client or using drugs in the presence of a client may be an expression of mutuality and trust, given that intoxication makes both parties more vulnerable. This resonates with other studies of drug-using subcultures which demonstrate the importance of sharing in drug users' social relationships (McKeganey, 1992, as cited in Rhodes et al., 1996). This ethos of mutual trust appears to help legitimate the sex-for-money-or-drugs exchanges. While many of those interviewed may seek to make their sex work congruent with mainstream gender role expectations by making their exchanges with clients impersonal and instrumental, thereby defining them as economic rather than emotionally intimate exchanges, others may seek to legitimate their exchanges by blurring the distinction between paid sex and unpaid sex, cultivating an atmosphere of friendship, trust, and intimacy with their clients.

Because of the cross-sectional nature of our study design, we were not able to follow up some of the themes that were raised by sex workers in the course of the interviews. For example, we could not return to the study participants after our initial analysis to ask more specifically how sharing, intimacy, economic pressures to engage in more highly paid sex practices, or concerns about cleanliness, hygiene, or the risk of pregnancy were seen by the sex workers, and how these considerations were weighed in specific negotiations with clients. Neither were we able to ask to what extent their decisions to cultivate more intimate personal relationships or spend significant time with clients were due to the possibility of higher earnings from those clients, and to what extent they satisfied a need to define the relationships as motivated by more than sheer economic concerns. Such divergent patterns of clientele cultivation and selection may also have been due to factors such as differences in addiction severity among sex workers and resulting differences in the extent to which they needed quick cash and were able to be selective about their clientele, as noted by ethnographers of drug-using sex workers from similar neighborhoods in Puerto Rico (A. Finlinson, personal communication, February 29, 2002). Understanding such calculations, motivations, and constraints is crucial to interpreting the behavior of sex workers as gender performance, and should be addressed in future studies designed to fully explore the perspectives and definitions of the sex workers themselves.

If we look at the narratives presented here as narratives of gender performance, however, the effect of such gender performance on a given sex worker's ability to negotiate safer sexual practices is ambiguous, as she simultaneously negotiates her competing interests of material, physical, and emotional survival. Only under select circumstances does the script of a sex worker's gender performance facilitate condom use. For example, while at times a sex worker's cultivation of a regular, trusted customer facilitates condom use because the customer expects it and is compliant, at other times a sex worker forgoes condom use with such a customer out of a sense that he is safer than unknown customers, and perhaps to emphasize mutual trust and intimacy in their relationship. Nonetheless, these narratives identify factors which should be considered in programs and policies designed to reduce HIV risk among Latina sex workers. The sex workers interviewed in this study explained their sexual and drug-using behaviors with clients in terms of their efforts to preserve their sense of dignity within their relationships with clients, in terms of their roles as mothers, and in terms of their vigilance with regard to physical as well as social hygiene (i.e., the cleanliness and moral appropriateness of their clients). Such explanations were crucial to making sense of their choices within a landscape of threats to their survival.

However, we must not lose sight of the powerful structural constraints that this toxic landscape puts on the "choices" of these women. For example, the fact that they engage in high risk sexual behavior to provide for their children's necessities emphasizes the degree to which our broader society denies public responsibility for protecting and nurturing vulnerable women and their children. Such a "choice" is better seen as the effect of what observers of poverty and suffering term structural violence (Bourgois, 2001). Social and economic policies which permit the high levels of poverty seen in Puerto Rico, as well as aggressive antinarcotics campaigns which emphasize heightened arrests and sentencing rather than the provision of health care and social services for substance-abusing women and men, are thus appropriate targets for HIV-prevention efforts.

At the same time, as many HIV researchers have observed in the past, we cannot afford to wait for such major structural shifts to take place before introducing local-level, practical interventions. Based on the findings presented here, we suggest that future HIV-prevention efforts frame condom use and other self-protective behaviors in terms that build upon sex workers' own strategies for understanding their options and modifying their risks. For example, condoms might be promoted as an essential part of hygiene maintenance with clients. Also, as Castaneda et al. (1996) suggest in their study of Mexican female sex workers, safer sex might be promoted as a way to protect one's family, as maternity is also the only area where AIDS is an unlimited threat. As they explain, "In these women's double lives, the life and identity which they consider valuable and worth protecting is their life as mothers" (p. 242). Since the women quoted here also strove to maintain a sense of mutuality in their dealings with regular clients, "safer" sexual practices might be promoted as actions that protect and respect valued acquaintances. Such an approach to HIV prevention acknowledges that at stake in any sexual negotiation may be the participants' very identity as women (or men), and their sense of worth within the context of their known social universe.

Table 1. Demographic Profile of Study Participants

Variable                                  Mean  Range   Percent

Age (years)                               28    19-39
Years of school completed                  9.5   1-7
Number of children                         2.8   0-9
Birthplace
   Puerto Rico                                            79.2
   United States                                          19.2
   Dominican Republic                                      1.0
   Other countries                                         0.6
Civil status
   Married                                                 5.1
   Divorced                                               19.6
   Living with partner                                    18.6
   Separated                                              16.1
   Widow                                                   5.1
   Single never married                                   35.4
History of non-HIV sexually
 transmitted disease (self-report)                        34.3
HIV positive (by ELISA and western blot)                  29.6
Has used crack cocaine (self-report)                      39.2
Has used powder cocaine (self-report)                     34.7
Has used heroin (self-report)                             60.5
Has used speedball (injected heroin and
 cocaine together; self-report)                           55.6
Has injected drugs                                        45.3
Injected drugs today or yesterday
 (of those who have injected) (a)                         93.7

Note. N = 311.
(a) n = 158 (12 missing values).

Table 2. History of Sex Work

Variable                                        Percent

Primary employment
   Prostitution                                   94.5
   Other employment                                1.0
   Unemployment                                    4.2
   Out of labor force                              0.3
Days of the month engaged in sex work
   <8                                             16.0
   8-15                                           18.7
   16-29                                          17.2
   30-31                                          48.1
Age of initiation
   7-12 years old                                  3.4
   13-19                                          30.7
   23-30                                          53.2
   31+                                            12.7
Years active in sex work
   <1                                             17.2
   1-5                                            50.4
   6-10                                           17.5
   11+                                            14.9
Used drugs when started sex work                  80.6
Primary place where clients are solicited (a)
   Street                                         67.5
   Bars                                            7.5
   Drug-dealing site                               1.9
   Brothel                                         0.7

Note. N = 311.

(a) There are 70 missing values for this question.

Table 3. Beliefs About Risk of HIV Infection

Response category                                             Percent

       Probability that your primary sexual partner is infected
              with the virus that causes AIDS (a)

None                                                             57.1
Low                                                              16.2
Medium                                                           13.5
High                                                             13.1

        Probability that you (respondent) are infected with the
                   virus that causes AIDS (b)

None                                                             43.7
Low                                                              15.7
Medium                                                           19.9
High                                                             20.7

            What makes you think that (this is your probability
                          of infection)? (c)

Condom use and/or clean injection equipment                      30.3
"Protects" or "cares for" self (method not indicated)            20.5
Took HIV test                                                    14.3
Spouse took HIV test                                              0.8
Symptoms--feeling healthy or ill                                  5.3
Clean/known/healthy clients or partners                           6.1
Prostitution                                                      3.0
Streets                                                           3.8
Risk from sex or partner                                          3.0
Drug use or injection                                             4.2
"I'm at risk"                                                     1.5
"I know"                                                          1.1
Don't know                                                        3.0
Other (unique responses)                                          7.2

    Example of something that represents a danger to your life (d)

AIDS/HIV                                                         23.0
HIV risk behavior (sex without condoms or shared needles)         6.3
Not using "protection" (unspecified)                              2.3
Murder, being shot or assaulted                                  18.8
Rape                                                              3.9
Drugs (unspecified)                                               6.9
Injection drugs                                                   1.6
Overdose                                                          3.9
Non-HIV disease (e.g. cancer, hapatitis, pneumonia)               7.2
Clients (unknown or crazy)                                        3.0
Husband or ex-husband                                             2.0
Prostitution                                                      2.6
The streets (unspecified)                                         3.3
Death                                                             2.0
Nothing                                                           3.3
Don't know                                                        1.6
Other (unique responses)                                          8.2

       How does this danger compare with the risk of infecting or
       reinfecting yourself with the virus that causes AIDS? (e)

AIDS/HIV or risk behavior (sex without condom or sharing
 needles) is greater danger                                      36.4
Dangers are equal                                                29.6
Other danger is greater                                          12.0
Don't know                                                        4.4
Already have HIV or AIDS                                          1.6
Dangers cannot be compared                                        1.6
Neither is important                                              2.0
Other (unique responses)                                         12.1

(a) n = 311.

(b) n = 311.

(c) n = 264 (open-ended responses, thematically coded,
some respondents gave more than one answer).

(d) n = 304 (open-ended responses, thematically coded).

(e) n = 250 (open-ended responses, thematically coded).

REFERENCES

Alegria, M. (1998). Hispanic women. In A. Wetherington & C. Roman (Eds.), Drug addiction research and the health of women: Executive summary (pp. 123-126). Washington, D.C.: U.S. Department of Health and Human Services.

Alegria, M., Vera, M., Freeman, D., Robles, R., del C. Santos, M., & Rivera, C. (1994). HIV infection, risk behaviors, and depressive symptoms among Puerto Rican sex workers. American Journal of Public Health, 84, 2000-2002.

Alegria, M., Vera, M., Rivera, C., Burgos, M., Finlinson, A., & del C. Santos, M. (1994). Puerto Rican sex workers: HIV risk behaviors and policy implications. Centro de Estudios Puertorriquenos, 6, 86-93.

Alonso, A., & Korek, M. (1989). Silences: `Hispanics,' AIDS, and sexual practices. Differences, 1, 101-124.

Amaro, H. (1995). Love, sex and power: Considering women's realities in HIV prevention. American Psychologist, 50, 437-445.

Barkley, B., & Salazar-Mosher, E. (1995). Sexuality and Hispanic culture: Counseling with children and their parents. Journal of Sex Education and Therapy, 21, 255-267.

Bernard, H. (1995). Research methods in anthropology: Qualitative and quantitative approaches. Thousand Oaks, CA: Sage Publications.

Biemiller, L. (1991). Campus health experts are frustrated about progress on AIDS education. Chronicle of Higher Education, 38 (17), A33-35.

Bourgois, P. (1999). Theory, method and power in drug and HIV-prevention research: A participant-observer's critique. Substance Use and Misuse, 34, 2155-2172.

Bourgois, P. (2001). The power of violence in war and peace: Post-Cold War lessons from El Salvador. Ethnography, 2 (1), 5-37.

Bourgois, P., & Dunlap, E. (1993). Exorcising sex for crack: An ethnographic perspective from Harlem. In M. Ratner (Ed.), The crack pipe as pimp (pp. 97-132). Lexington, MA: Lexington Books.

Browne, J., & Minichiello, V. (1995). The social meanings behind male sex work: Implications for sexual interactions. British Journal of Sociology, 46(4), 598-622.

Burgos, M., Richter, D., Reininger, B., Coker, A., Saunders, R., Alegria, M., et al. (1999). Street-based female adolescent Puerto Rican sex workers: Contextual issues and health needs. Family and Community Health, 22, 59-71.

Castaneda, X., Ortiz, V., Allen, B., Garcia, C., & Hernandez-Avila, M. (1996). Sex masks: The double life of female commercial sex workers in Mexico City. Culture, Medicine and Psychiatry, 20, 228-247.

Centers for Disease Control and Prevention. (1999). HIV/AIDS Surveillance Report, 11, 5-10.

Chavez, L. (1998). No to Puerto Rican statehood. Human Events, 54, 1.

Colombiani, J. (2001, January 30). Esfuerzo minimo contra el vicio [Minimal force against vice]. Nuevo Dia, p. 4.

Colon, H., Canino, G., Robles, R., Toro, C., Lopez, C., & Orraca, O. (1998). Household study, needs assessment program for substance abuse services. Commonwealth of Puerto Rico: Mental Health and Anti-Addiction Services Administration.

Comas-Diaz, L. (1987). Feminist therapy with mainland Puerto Rican women. Psychology of Women Quarterly, 11, 461-474.

Corby, N. (1991). AIDS knowledge, perception of risk, and behaviors among female sex partners of injection drug users. AIDS Education and Prevention, 3, 353-366.

De Graaf, R., & Vanwesenbeeck, I. (1994). Male prostitutes and safe sex: Different settings, different risks. AIDS Care, 6, 277-289.

De Graaf, R., Vanwesenbeeck, I., Vanzessen, G., Straver, C., & Visser, J. (1995). Alcohol and drug use in heterosexual and homosexual prostitution, and its relation to protection behavior. AIDS Care--Psychological and Socio-Medical Aspects of AIDS/HIV, 7, 35-47.

Deren, S., Shedlin, M., Davis, W., Clatts, M., Balcorta, S., Beardsley, M., et al. (1997). Dominican, Mexican, and Puerto Rican prostitutes: Drug use and sexual behaviors. Hispanic Journal of Behavioral Sciences, 19, 202-213.

Dunn, J. L. (1998). Defining women: Notes toward an understanding of structure and agency in the negotiation of sex. Journal of Contemporary Ethnography, 26, 479-510.

Ehlers, T. (1991). Debunking marianismo: Economic vulnerability and survival strategies among Guatemalan wives. Ethnology, 30, 1-14.

Estebanez, P., Fitch, K., & Najera, R. (1993). HIV and female sex workers. Bulletin of the World Health Organization, 71, 397-412.

Farmer, P., Connor, M., & Simmons, J. (1996). Women, poverty and AIDS: Sex, drugs, and structural violence. Monroe, ME: Common Courage Press.

Flaskerud, J. H., & Ruiz-Calvillo, E. (1991). Beliefs about AIDS, health and illness among low-income Latina women. Research in Nursing and Health, 14, 431-438.

Fullilove, M. T., Lown, A., & Fullilove, R. E. (1992). Crack `hos and skeezers: Traumatic experiences of women crack users. The Journal of Sex Research, 29, 275-287.

Gil, V. E. (1995). The new female condom: Attitudes and opinions of low-income Puerto Rican women at risk for HIV/AIDS. Qualitative Health Research, 5, 178-203.

Hardesty, M., & Black, T. (1999). Mothering through addiction: A survival strategy among Puerto Rican addicts. Qualitative Health Research, 9, 602-620.

Holland, J., & Ramazanoglu, C. (1990). Managing risk and experiencing danger: Tensions between government AIDS education policy and young women's sexuality. Gender & Education, 2, 125-143.

Inciardi, J. (1993). Women and crack cocaine. New York: Macmillan Press.

Kane, S. (1998). AIDS alibis: Sex, drugs and crime in the Americas. Philadelphia: Temple University Press.

Kelly, J., & Murphy, D. (1991). Some lessons learned about risk reduction after ten years. AIDS Care, 3, 251-258.

Khalsa, M., & Kowalewski, M. (1994). AIDS-related knowledge, beliefs and risk behaviors in a sample of crack addicts. Journal of Drug Issues, 24, 537-554.

Latinamerica Press. (2001). Ban the bombing. Retrieved January 14, 2002, from http://www.lapress.org/Summ.asp?lanCode=1&couCode=21

MacPhail, C., & Campbell, C. (1999). Evaluating HIV/STD interventions in developing countries: Do current indicators do justice to advances in intervention approaches? South African Journal of Psychology, 29, 149-166.

Mayo, Y., & Resnick, R. (1996). The impact of machismo on Hispanic women. Affilia: Journal of Women & Social Work, 11, 257-278.

Messerschmidt, J. (1997). Crime as structured action: Gender, race, class and crime in the making. Thousand Oaks, CA: Sage Press.

Moore, J., Harrison, J., Kay, K., Deren, S., & Doll, L. (1995). Factors associated with Hispanic women's HIV-related communication and condom use with male partners. AIDS Care, 7, 415-427.

Pyett, P., & Warr, D. (1997). Vulnerability on the streets: Female sex workers and HIV risk. AIDS Care--Psychological and Socio-Medical Aspects of AIDS/HIV, 9, 539-547.

Rhodes, T., Stimson, G., & Quirk, A. (1996). Sex, drugs, intervention, and research: From the individual to the social. Substance Use and Misuse, 31, 375-407.

Simmel, G. (1950). The sociology of Georg Simmel. New York: Free Press. Simon, P. (1994). Income and AIDS rates in Los Angeles County. AIDS, 9, 281-284.

Stevens, E. (1973). Machismo and marianismo. Society, 10, 57-63.

Suarez, Z., & Siefert, K. (1998). Latinas and sexually transmitted diseases: Implications of recent research for prevention. Social Work in Health Care, 28, 1-19.

Tice, T. (1992). HIV/AIDS knowledge. Education Digest, 58, 47.

Waddel, C. (1996). HIV and the social word of female commercial sex workers. Medical Anthropology Quarterly, 10, 75-82.

Weeks, M., Grier, M., Romero-Daza, N., Puglisi-Vasquez, M. J., & Singer, M. (1998). Streets, drugs, and the economy of sex in the age of AIDS. Women and Health, 27, 205-229.

Wood, M., & Price, P. (1997). Machismo and marianismo: Implications for HIV/AIDS risk reduction and education. American Journal of Health Studies, 13, 44-53.

Helena Hansen
Yale University

Maria Margarita Lopez-Iftikhar

Margarita Alegria
University of Puerto Rico School of Public Health

The authors would like to thank the National Institute of Drug Abuse and the Hispanic Research Center of University of Texas, San Antonio Branch for sponsoring the training program which made this analysis possible. We would also like to thank Doctors Mildred Vera, Ann Finlinson, and Maureen O'Dougherty for their helpful comments on earlier drafts of this paper, as well as Kim Blankenship for her clear articulation of the theoretical issues explored here. Finally, we would like to thank the three reviewers of this paper for their thoughtful comments which helped enormously to strengthen our analysis and the presentation of our data. The data collection for this study was supported by the National Institute of Allergy and Infectious Disease grant number RR03051.

Address Correspondence to Helena Hansen, M.D.-Ph.D. Candidate, Yale University, Departments of Anthropology and Medicine, P.O. Box 208277, New Haven, CT 06520-8277; e-mail: [e-mail]. ). Rapport fr

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