Sexual orientation further affects these men’s perceptions of risk and preventive behavior. While some identify as gay and describe escaping severe discrimination in their home countries (where, as one noted, “being gay is worse than being a prostitute”), many consider themselves heterosexual (Gille, 2007; KISS, 2012; LOOKS, 2012). Others identify as bisexual or, in the words of one social worker, “aren’t quite sure yet—they are still experimenting.” In an annual report from one of the organizations serving MSWs, 51.3 percent identified as heterosexual, 23.5 percent as homosexual, 20.2 percent as bisexual, and less than 1 percent as transgender; 44 percent did not provide information on sexual orientation (LOOKS, 2012). Another source reports that 36 percent defined themselves as heterosexual, 30 percent as homosexual, and 33 percent as bisexual (Steffan & Sokolowski, 2008). Some also report being hired by female clients; thus their sexual reality is complex, making the label of men who have sex with men not necessarily accurate, although it is the most dominant aspect of their work lives. In their private lives, however, it is not uncommon for the young men to be married, and some bring their wives and children to Germany with them. Since many plan on having children, condom use in these marital relationships is atypical. Moreover, truthful disclosure of their work life in Germany is uncommon. “My girlfriend [in Romania]?” one young man told me, “I tell her I am working for my uncle on construction sites.” Since many of the boys identify as heterosexual, organization staff serving MSWs in the various metropolitan settings often encourage them to think about sexuality as encompassing a range of forms and that “what’s in their head does not have to always match the actions of their body.” Put another way, one social worker emphasizes that “hustling is hustling, it has nothing to do with your sexuality.”
To complicate preventive health efforts, many MSWs claim that they only practice a sexually active (insertive) role, due to social taboos surrounding homoeroticism. Certain acts may be considered homosexual while others are not; as long as they do not perform any of these techniques or do not confess to offering them (or enjoying them), they are generally able to reconcile their sex work with their preferred identity. Social workers and physicians noted a disconnect between this discourse and everyday practice, however, as the men likely participate in a range of sexual activities. This disconnect, according to one social worker, allows the men to preserve their dignity and to “show they are the ones in control.” These stigma management techniques minimize the effects of their marginality but also constrain their disclosure of sexual risks with their female partners. When asked about how this affects discussion of HIV prevention, one doctor said she “simply lay[s] out what can happen in both roles, that the passive role has a higher chance of [HIV] infection. They get both messages.”
While only a small percentage of health consultations were prompted by an STI, there was a strong emphasis on prevention and diagnosis. Out of 364 encounters in 2011, physicians working with the Berlin organization reported 38 STI diagnoses: gonorrhea (10, ~3 percent), chlamydia (10, ~3 percent), syphilis (7, ~2 percent), condyloma/genital warts (5, ~1.2 percent), hepatitis C (5, ~1.2 percent), and hepatitis B (1, 0.3 percent). Physicians also provided significant preventive care, educating about STIs in 37 percent and hepatitis in 31 percent of their encounters with MSWs, and providing a hepatitis vaccine in 11 percent. A study from Dortmund found that about 50 percent of male sex workers had been vaccinated against hepatitis A/B, confirming the success of outreach efforts. However, only 46 percent said they had ever had an STI checkup, and only 2 percent of those had taken place in the previous two years. The most frequent illnesses mentioned in the study were gonorrhea and syphilis (Steffan & Sokolowski, 2008).
Because organizations serving MSWs generally do not test for HIV on site for a number of logistical and ethical reasons, these men are referred to the health department. In many cities, the department is considered a trusted place where the men recognize people because they become familiar with health department staff during medical visits at the drop-in centers. Gonorrhea, chlamydia, and syphilis can be treated for free. Syphilis is easily treated with a monthlong course of pills or weekly injections; one health department physician shared her preference for injections because of this group’s irregular lifestyle. If they insist on pills, she will “only give them a week’s supply at a time to be sure they return for follow-up.” In this way, she tries to ensure that therapy continues and that the men avoid losing or sharing their pills. Hepatitis is more difficult to treat; health departments reported having the ability to treat type B only as it becomes symptomatic, and treatment for hepatitis C is simply too expensive for the uninsured men (500-600 euros, or about US$600-$720 a month). In these cases, patients are monitored but not treated, which often opens up a dialogue about the benefits of obtaining health insurance in their home country and then applying for the EU Health Insurance Card to reduce their out-of-pocket portion.
Some medical and health outreach staff stated that they found it ethically problematic to test people for HIV when therapy is out of reach. A range of strategies must be considered if an uninsured person is diagnosed as HIV positive, but it still becomes, as one social worker noted, a “matter of luck” whether they are able to access treatment. HIV/AIDS does not qualify as an acute illness eligible for coverage by the state, even though, as the same social worker noted wryly, he has seen other cost-intensive treatments like chemotherapy approved. Ultimately, a migrant MSW diagnosed with HIV/AIDS has three options. First, he can apply for unemployment benefits on the grounds that the illness prevents him from working; this is problematic if he was never eligible to work in the first place because of the German labor market restrictions mentioned earlier. Second, if he has obtained a small business license, he may become eligible for health insurance coverage through the unemployment system after proving to have insufficient income. Finally, the best option may simply be to return to his country of origin, especially if social workers are able to locate treatment resources there. Wide networks are cultivated in other countries for this very reason. However, one social worker stressed that HIV is generally acquired in Germany, therefore it is “simply not fair to send them back to their countries, as this shifts responsibility away” from the host society. Indeed, epidemiological data support the fact that, among migrant men who have sex with men, more than 90 percent acquired the infection in Germany (Robert Koch-Institut, 2010).
Discussion
As explained above, constrained options resulting from national policies that restrict access to the labor market clash with the promise of economic opportunity through freedom of movement across EU borders. This reality is framed by multiple disadvantages, including poverty, discrimination, unemployment, and low educational attainment. Structural transformations in the economy that lead to an increase in men’s labor migration increase the likelihood that a given individual will be confronted with the possibility and the need to exchange sex for money (Padilla, 2007).
In Western Europe, a high demand for sexual services meets a relatively unregulated market, despite instances of legalization. In Germany, selling sex is considered a legitimate economic activity, and the 2002 Act Regulating the Legal Status of Prostitutes protects sex workers from discrimination, strengthens their legal rights, and promises regular screenings and eligibility for the statutory health insurance system as self-employed individuals, which has a positive impact on individual and public health. Excluded from these benefits, however, is the large population of migrant sex workers without clear legal status or a work permit, and no improvement in the situation of migrant MSWs is evident, based on Germany’s 2002 prostitution law. Already critiqued for its vague components, inconsistent implementation, and the fact that most sex workers remain unfamiliar with its provisions (Helfferich, 2005), I would add that MSWs are not the primary beneficiaries of the law and that some migrant groups cannot even apply for the work permits necessary to take advantage of its protections.
This example also demonstrates that there are significant limits to the entitlements and meaning associated with what, on the surface, appear to be widening citizenship practices. These practices negatively affect the health of marginal populations, like migrant MSWs from poor EU countries who live in more prosperous ones, as citizenship constructs solidify new and existing inequalities. The high proportion of Romanian and Bulgarian MSWs in Germany is clearly linked to the expansion of the EU and the limited employment opportunities associated with transitional measures imposed by the German government. In previous years—and immediately following their countries’ entry to the EU—young men from Poland and the Czech Republic filled these positions. As the transitional measures were lifted, their numbers decreased. One health department physician said she was able to “literally watch the borders shift, based on the patients that came in,” noting that they had to fire some of their best interpreters when, for example, Polish language skills were no longer needed. The same process, she and others reasoned, will undoubtedly unfold with Bulgarians and Romanians once the transitional measures are lifted in 2014 and other employment options become available. Presuming continued demand for male sex work, the question remains: from where will the next waves of multiply structurally disadvantaged young men come?
This chapter argues for going beyond targeting “risky men,” which leads to further stigma, and focusing instead on the ways men move in and out of risky social contexts and how focusing on their structural vulnerability can help us understand mutually reinforcing insults that have a negative impact on health at the economic, political, cultural, and individual levels. It encourages researchers and social workers working with MSWs to move beyond the basic association between sex work and HIV to contextualize health risks as a result of macro-level processes, including immigration and restrictive labor policy. In the case of Germany, as discussed here, access to medical services is sharply limited for sex workers whose socio-legal position resembles that of irregular migrants and is indicative of fragmentary membership and asymmetrical citizenship practices in the EU (Castañeda, 2011). Migrant MSWs are largely excluded from medical care or are treated by ad hoc clinics that cannot cover the entire range of treatment needs. These include everyday medical concerns and experiences of violence, which are often obscured in the myopic focus on HIV (Dennis, 2008). The data presented here indicate that MSWs face many of the same health issues as unauthorized migrants, particularly a lack of dental and mental health-care options (Castañeda, 2009).
Migration of MSWs between German cities and their home communities creates a shift in the meanings and practices of masculinity. Thus, “the gender imperative for men to provide economically for their families may ironically increase the chances that female partners and children will be affected by the AIDS epidemic as male labor migrants engage in high-risk sexual practices for instrumental purposes while geographically separated from families and communities” (Padilla, 2011, p. 162). This study also noted patterns of selective condom use, whereby MSWs generally used condoms with male clients but not with trusted male or female intimate partners. In addition, in the interviews described here, some also refused condom use with female partners because they wanted to become fathers. Thus, rather than attributing this to a lack of knowledge or willingness to engage in risky behavior, it should be understood within the context of long-term social goals and responsibilities.
Anthropologists contributed to the development of more nuanced perspectives in the early years of the AIDS epidemic by questioning the assumed congruence between sexual identity and behavior. Ethnographic data point to a variety of cross-cultural constructions of gender, and to the importance of structural processes for sexual meaning and practices. The exchanges in which MSWs engage unfold “within a much more fluid pattern of behavioral and situational bisexuality than the narrowly heterosexual pattern described in most prior studies” (Padilla, 2007, p. 7). Such men are largely invisible to research models that rely on discrete concepts of sexual identity and obfuscate the fact that bisexual behavior may be an integral feature of sexual life and the epidemiology of HIV. Indeed, sexual identity is actually irrelevant to the transaction, which more often revolves around the roles played by the partners (e.g., active/passive; Dennis, 2008). Thus, while important information for prevention efforts, it is not a new finding that MSWs claim to participate in active or insertive anal sex with male partners or that many consider themselves heterosexual. This is underscored in literature on MSWs from across the globe, including earlier research among Bulgarian and Romanian (Gille, 2007) and Turkish MSWs in Germany (Bochow, 2003), and on sexual norms among Roma in Bulgaria (Kelly et al., 2004). The resulting discrepancies between MSWs’ statements and their actual sexual practice should be viewed as a way they deal with complex pressures and constraints. Health promotion projects are hindered by inaccurate or unrealistic conceptualizations of sexual behavior, as well as a stubborn focus on narrowly framed risk groups (men who have sex with men or sex workers), rather than on causal factors that shape the social context of risk. Traditional public health approaches are largely incapable of capturing the nuances of MSWs’ intimate experiences and how this risk behavior is shaped by larger structural factors.
References