Differential HIV Risk in Bathhouses and Public Cruising Areas

Social scientists have investigated the environments outside the home where men who have sex with men (MSM) meet other MSM for casual, usually anonymous sex. The variety of settings is large, but they generally allow participants to secure a minimum of privacy, at least in terms of not being harassed or interrupted. Some of the venues are purely public spaces (e.g., parks, beaches, alleys, and toilets), and some are commercial environments that can also serve as sex venues (e.g., adult bookstores, pornographic movie houses, back rooms of bars, and traditional Turkish or Japanese bathhouses). The general purpose of all these venues is something other than providing opportunities for sex. Consequently, MSM who frequent these venues share them with people who are not seeking sexual encounters on the premises, and MSM take certain risks in looking for sexual encounters, including risk of discovery, physical harm, or arrest.

Because the association between HIV and baths was identified early in the epidemic, investigators have given considerable attention to sex venues generally. Using data from a probability sample of urban MSM, the present analysis describes the characteristics of men according to their pattern of sex venue attendance: whether they went only to public cruising areas ("cruisers"), only to baths ("bathers"), or to both public cruising areas and baths ("multivenue users"). The data are from the Urban Men's Health Study, a telephone survey based on a probability sample of men 18 years or older who self-identified as gay or bisexual or who reported sexual contact with a man since 14 years of age. Briefly, the sample design used multiple data sources to identify geographic areas in New York, Chicago, Los Angeles, and San Francisco that reflected residential clustering of MSM populations. Using disproportionate and adaptive sampling techniques, the researchers then constructed a random-digit-dialed sample for the designated target areas within each city. With computer-assisted telephone interviewing, the authors conducted 2,881 interviews with MSM in English or Spanish, achieving a completion rate of 78 percent.

Interviews covered a range of social, psychological, and health-related topics, with an emphasis on HIV-related issues. HIV-status was self-reported. Respondents were asked a series of questions related to frequenting specific sex venues in the past 12 months. Men were also asked to describe their same-sex sexual practices for the past 12 months, including number of partners, number of "one-night stands," whether they engaged in unprotected anal intercourse, and whether such intercourse occurred in group or in public settings or outside the confines of a primary relationship. To control for a major co-factor of HIV risk behavior, the authors included in this analysis usage of four drugs that tend to be associated with casual sex: poppers (i.e., nitrites), ecstasy, methamphetamines, and other party drugs (such as ketamine and rohypnol).

For the analyses in this report, the sample was limited to men who reported having sex with a man in the past year (n=2,478). Overall, about half of the MSM in our sample reported going to a sex venue. Younger and less-educated men were more likely to visit a sex venue. Of all the men going to sex venues, 75 percent went to public cruising areas and 61 percent to baths. Bathers and multivenue users were more likely than cruisers to be HIV-positive, to have had a STD, and to report using poppers, ecstasy, methamphetamines, and other party drugs. The multivariate analysis indicated that bathers and multivenue users were significantly more likely to engage in unprotected anal intercourse in a public setting than were cruisers and that frequent venue attendees were more likely to have such intercourse in public than less frequent attendees.

The results suggest that sex venues play an important role in the sexual lives of gay men. However, it was encouraging to learn that most of those visiting sex venues did not engage in sexual risk behaviors. Findings associated with serostatus and sexual risk behavior indicated that HIV-positive men remain sexually active, seek sexual partners in the same settings as uninfected men, and are more likely to engage in unprotected anal intercourse in a public setting. The most striking finding was a consistent pattern across all drug- and sex-related risk behaviors: multivenue users were the most likely to report risky behavior and cruisers were the least likely.

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