Street Workers and Internet Escorts: Contextual and Psychosocial Factors Surrounding HIV Risk Behavior among Men Who Engage in Sex Work with Other Men

Abstract

Sex work has been associated with elevated risk for HIV infection among men who have sex with men (MSM) in many settings. This mixed methods study examined sexual risk among MSM sex workers in Massachusetts, collecting formative data on HIV risk behavior by sex worker type in order to gain a better understanding of how to tailor prevention interventions to this unique and high-risk subgroup of MSM. Two groups of MSM sex workers were recruited between January and March 2008: street workers (n = 19) and internet escorts (n = 13). Participants completed a semistructured qualitative interview and quantitative psychosocial assessment battery; interviews were conducted until redundancy in responses was achieved. Almost one third (31%) were HIV-infected. The majority of participants (69%) reported at least one episode of unprotected serodiscordant anal sex (either insertive or receptive) with a mean of 10.7 (SD = 42.2) male sex partners of an unknown or different HIV serostatus in the past 12 months. Salient findings included: (a) internet sex workers reported being paid substantially more for sex than street sex workers; (b) inconsistent condom use, high rates of unprotected sex, and low rates of HIV status disclosure with sex work partners for both internet and street workers; general perceptions of a lack of trust on the part of sex work partners (i.e., telling them what they want to hear), offers of more money for unprotected sex; (c) contextual differences in risk taking: internet sex workers reported that they are more likely to engage in sexual risk-taking with noncommercial sex partners than sex partners who pay; (d) HIV status and STI history: two street workers became infected in the context of sex work, and 25% of the entire sample had never been tested for sexually transmitted infections (STI); and (e) motivations and reasons for doing sex work, such as the “lucrativeness” of sex work, as a means to obtain drugs, excitement, power, “why not?” attitude, and because social norms modeled this behavior. Study findings can be used to generate hypotheses for designing and providing tailored primary and secondary prevention interventions for this at-risk subgroup of MSM.

Introduction

Sex work has been associated with elevated HIV risk-taking and/or seropositivity among men who have sex with men (MSM),^1,2 the population of individuals representing the largest number of new infections (67%) and almost half of all Americans living with HIV (49%) at the last reporting period, 2006.³ In existing sample studies, men involved in sex work with other men have been shown to be at increased risk of HIV infection⁴ with a significantly higher HIV prevalence (7.3% versus 1.1%, p < 0.001) and HIV incidence (4.7% versus 0.9%, p = 0.01) compared to their nonsex work counterparts.¹ Prior research has documented that 42% of seropositive sex workers were unaware of their infection.² Moreover, men who engage in sex work with other men have been found to be more likely than nonsex-working MSM to engage in unprotected sex with male and female nonprofessional partners.^5–7 Taken together, these data suggest that this subset of MSM may be a particularly important “bridge” population that may increasingly transmit HIV and other STIs to nonsex work partners.

It is important to understand the factors that lead to and potentiate HIV risk behavior among MSM sex workers in order to develop culturally appropriate prevention interventions. Prior research has revealed an association between sex work and crack use, injection drug use, childhood sexual abuse, nongay self-identification, and homelessness.^8,9 Moreover, regular and heavier use of alcohol and drugs, unemployment, history of residence in a psychiatric ward, and bisexual activity have each been shown to be independently associated with trading sex for money, drugs, housing, or other goods.¹ With respect to HIV risk behavior, differences have been observed in terms of where male sex workers meet their clients.^10,11 Specifically, men who found clients on the street reported the highest rates of HIV risk behavior both with sex work partners and nonsex work partners.^5,12–14 However, in comparison, sex workers who found clients via the internet reported lower rates of HIV risk behavior with their sex work partners than with their nonsex work partners.^15,16 Several recent studies suggest that sexual risk behavior among male sex workers may be related to a number of contextual and psychosocial factors (e.g., depression, substance and alcohol addiction, housing issues) that function independently of sex work.¹⁷ Because of this, these factors may influence sex workers in greater proportion than among other groups of MSM.^7,16,18,19 Additional research is warranted to further explore differences in behavioral, psychosocial, and sexual risk factors among male sex workers, in particular between MSM who meet transactional partners via the internet and those who do not.^20–22

There exists a lack of culturally relevant prevention interventions for MSM sex workers. Given the data showing that sexual and drug risk patterns may differ between internet MSM sex workers and street MSM sex workers, optimal intervention approaches for these two groups may differ. The purpose of the current study was to collect formative data on HIV risk behavior among MSM who engage in sex work and to investigate differences in risk behavior by sex worker type (street workers versus internet escorts) to inform prevention interventions or programs. This is the first mixed methods study to examine differences in sex work between street workers and internet escorts among Massachusetts MSM.

Methods

Participants and Procedures

Between January 2008 and March 2008, 32 participants completed a one-on-one in-depth semistructured interview and brief survey lasting approximately 1.5 h in duration with one of two trained interviewers. Participants were eligible if they were born male, were 18 years of age or older, lived in Massachusetts, and reported they had engaged in sex work with another biologic male in the 12 months prior to study enrollment. Sex work was defined as the exchange of sex for money, drugs, housing, protection, or other goods.

Each interview was digitally recorded and then transcribed verbatim by a professional transcription company. After completing the interview, each participant was administered a brief psychosocial assessment battery that included demographics, HIV/STI testing history, sexual behavior, early sexual experiences, drug and alcohol use, and depression.

All study activities took place at Fenway Community Health (FCH), a freestanding health care and research facility specializing in HIV/AIDS care and serving the needs of the lesbian, gay, bisexual, and transgender community in the greater Boston area.²³ The FCH Institutional Review Board approved the study, and each study participant completed an informed consent process.

Recruitment

Two methods were employed to recruit two subgroups of participants. Street workers (n = 19) were recruited via word-of-mouth referrals and study flyers which were disseminated in the clinical and medical areas at FCH, in known public sex cruising areas, at community events frequented by members of the target population, and at other local community-based organizations in the Boston area. Internet escorts (n = 13) were recruited strictly through internet chat rooms and online sex sites. Boston-area MSM with public profiles advertising sex in exchange for money or other compensation were directly e-mailed study information regarding participation. All participants were remunerated 50 dollars for their participation in the study.

Development of Study Instruments

Interview

Qualitative Interview Guide The interview guide was developed by conducting a thorough literature review and gathering input from former sex workers as well as MSM health specialists at FCH to ensure cultural relevance of survey instruments. The guide included the following topic areas: experiences with sex work in the past 12 months; history of involvement with sex work; and HIV/STI risk (perception of HIV/STI risk, condom use, sex work versus nonsex work partners, HIV serostatus disclosure, and communication about HIV/STIs and attitudes about potential prevention interventions).

Survey

Demographics, Sexual Behavior, and Drug Use Questions Questions examining demographics, sexual behavior, and drug use during sex were adapted from the Centers for Disease Control and Prevention’s National HIV Behavioral Surveillance Survey, MSM cycle,²⁴ and from a previous FCH study focusing on MSM perceptions of HIV/STI risk.²⁵ The survey also captured self-reported HIV status and testing history, as well as STI history.

Alcohol Use The CAGE questionnaire, a clinical screening instrument for alcoholism (Cronbach’s alpha = 0.69), was used to assess alcohol use where a score of 2 or more indicated a problem with alcohol.^26–28

Sexual History and Experiences Questions taken from the EXPLORE study, a large multisite intervention study of MSM in the U.S.,^29,30 were adapted to examine the occurrence of early childhood sexual experiences and their association with HIV-related sexual risk. These questions have been shown to be predictive of unprotected anal sex, unprotected serodiscordant anal sex, and HIV seroconversion in the EXPLORE study.³¹ Also included was a question to examine the prevalence of nonconsensual sex (e.g., rape) in adulthood.

History of Incarceration, Psychiatric Hospitalization, and Drug and/or Alcohol Treatment Participants were asked whether they had ever spent time in jail or prison, whether they had ever been hospitalized for psychiatric reasons, and whether they had ever been in treatment for drug and/or alcohol use at any time in their lives.

Depression Participants were also asked whether they had ever been given a diagnosis of clinical depression by a doctor, nurse, or other medical or mental health professional.

Data Analysis

Data analyses examined broad differences by sex work subtype (street workers vs. internet escorts). Interview data from this study were analyzed using content analysis.³² After transcripts were reviewed for errors and omissions, two study staff used the NVIVO software to thematically organize transcripts. Research staff then reviewed the coded transcripts and agreed on the final overarching themes. Data were reexamined and ongoing discussion between coders and study investigators allowed for further theorizing and making of interconnections between research questions and raw data. During this process, recruitment continued until the interviews generated redundant themes, as is typical in qualitative research.³³ Across the two groups, the most frequently discussed topic areas that emerged included: (a) sex work clients: meeting and payment; (b) sexual risk, condom use, and psychosocial factors; (c) sex for pay vs. sex for pleasure; (d) HIV status and STI history; and (e) motivations and reasons for doing sex work.

Survey data were used to provide a more comprehensive portrait of occurring themes, as well as to support qualitative results, and are integrated with the interview findings below. Descriptive analyses were conducted using the SPSS statistical software.

Results

Descriptive Statistics

Demographics The majority of participants (63%) were White; 16% Black/African American, 19% Hispanic/Latino, and 21% other (Alaskan Native, multiracial). Noteworthy demographic differences were observed between street workers and internet escorts. Compared to internet escorts, street workers had lower education levels (68% vs. 8% had a high school diploma or less), more frequently had unstable housing in the past 12 months (68% vs. 23%), and were more often unemployed or disabled (89% vs. 23%). Relative to street workers, internet escorts were younger (mean 27.9 [SD = 8.4] versus mean 42.6 [SD = 8.5]), more frequently self-identified as gay (69% vs. 47%), and a higher percentage were full- or part-time students (31% vs. 0%).

Substance Use In the past 12 months, participants reported having sex while using a variety of substances: 75% used marijuana, 53% cocaine, 31% crack, 22% crystal methamphetamine, 22% Viagra (nonprescribed), 22% painkillers (Oxycontin, Percocet), 19% poppers (amyl nitrite), 16% ecstasy (MDMA), 16% downers (Valium, Ativan, Xanax), 9% GHB, 6% ketamine, 3% hallucinogens (LSD, PCP, mushrooms), and 3% heroin. Six percent had injected drugs to get high in the prior 12 months. Ninety-one percent of participants reported having sex while drunk, and 50% of participants screened positive on the CAGE indicating probable alcoholism at the time of the study.Street workers had a higher frequency of crack (47% vs. 8%) and cocaine (63% vs. 38%) use during sex in the 12 months prior to study enrollment than their internet escort counterparts; they also had a higher rate of lifetime drug and/or alcohol treatment history (53% vs. 23%). Internet escorts reported higher rates of crystal methamphetamine use during sex in the past 12 months (31% vs. 16%).

Psychosocial Risk Factors Almost one third (32%) of the cohort had a history of depression. Forty-one percent of participants reported a history of childhood sexual abuse (CSA). One in four participants (25%) reported having been raped as an adult (age 18+). Street workers reported a greater history of incarceration (79% vs. 46%), as well as history of inpatient psychiatric hospitalization (37% vs. 15%) than internet escorts.

Sex Work Clients: Meeting and Payment

Street sex workers met clients in very different ways than those who used the internet. In the past 12 months, street workers reported meeting sex work partners in bars, clubs, on the streets, in popular cruising areas, through friends, and on “party lines” (phone chat lines). Only one street worker reported having ever met a sex work partner on the internet using a friend’s computer, and this did not occur in the 12 months prior to study enrollment. In terms of fees for service, street workers reported “taking whatever they could get,” often making between $20 and $80 for oral/anal sex. One participant reported having engaged in receptive anal sex for $5 one time because he was $2 short of the money he needed to get high on crack.

All internet escorts reported having met some sex work partners on the internet and most used the internet exclusively as their way to meet paying partners. Popular internet sites were adam4adam, Manhunt, Rentboy, Eros, Men for Rent, Stud Files, and Craigslist. Internet escorts reported making more money than street workers, between $100 and $500 for oral/anal sex with several reporting overnight stays up to $3,000. Several internet escorts also regularly participated in other aspects of the entertainment industry, including male stripping (for both male and female audiences) and pornographic film (mostly masturbation scenes).

Sexual Risk and Condom Use

Sexual Risk In the 12 months prior to study enrollment, internet escorts reported a higher mean number of male sex partners (mean 86.1 [SD = 83.7] vs. 18.3 [SD = 23.8]) and transactional sex work partners (mean 62.2 [SD = 64.4] vs. mean 10.9 [SD = 15.9]) relative to street workers. Overall, 69% of participants reported insertive or receptive unprotected anal sex with an average of 10.7 (SD = 42.2) male sex partners of an unknown or discordant serostatus in the past 12 months. Fifty percent of the sample reported unprotected receptive and 31% reported unprotected insertive anal sex with a male sex partner of an unknown or discordant serostatus in the past 12 months; 41% reported having receptive oral sex where a partner of a different or unknown serostatus ejaculated in their mouth.Both street workers and internet escorts reported inconsistent condom use with sex work partners:

You know, I use protection sometimes. I don’t other times. I need to get tested again, actually. (HIV-uninfected, internet escort)

Communicating about HIV/STIs in Sex Work Encounters When asked whether or not and how often HIV or STIs comes up in sex work encounters, the vast majority of participants said it is not a topic of discussion:

Very rarely. I would say maybe 80–90% of the time it’s mentioned in passing, but never has any paperwork ever been asked for, never has any precautions ever want to really be taken. It’s sad because it’s sort of a ‘don’t ask don’t tell’ theory. (HIV-uninfected, internet escort)

In explaining the reasons why there is not more discussion of HIV or STIs, participants often described lack of trust as being central:

If you just want to get in my fucking pants you’ll tell me anything, so I know you’re full of shit, one way or the other. So just don’t even bring up the question, you know. (HIV-uninfected, street worker)

Interestingly, several participants described how that lack of trust works both ways and that they had told sex work partners “what they want to hear” with respect to disclosing HIV status or STI history.

Other participants talked about indirect forms of communication around HIV/STIs. For example, one participant said he never directly asks about HIV or STIs, but looks around for signs that a client may be HIV-infected when he does a call:

I go in the bathrooms and look to see if they have meds…I always do that, if I am in the house or in their bathroom, and I feel bad, but I always do that. I was at this guys’ house; it was a beautiful, beautiful apartment, and I go in the bathroom, and I open the medicine cabinet and I saw Combivir, and it could have been his friend’s, but I was like oh God, he didn’t tell me. (HIV-uninfected, internet escort)

Some participants did not feel it necessary to discuss HIV or STIs because they practice behaviors that they consider puts them and sex work partners at little risk, most commonly oral sex without a condom:

I don’t bring it up, and I think this is sort of a non-topic with me because a lot of the things that I do I don’t consider as risky behavior. (HIV-uninfected, internet escort)

Several participants also remarked that they assume everyone is HIV-infected and that it doesn’t matter either way to them what a sex partner’s HIV status is.

Sex for Pay vs. Sex for Pleasure

Differences in Risk by Sex Work vs. Nonsex Work Partners Many internet escorts reported increased HIV/STI sexual risk-taking among casual or recreational sex partners relative to sex work partners:

I’ve never had—I’m not going to say never, but 99%—with a client, I’ve never had unprotected oral sex. With non-clients, I’ve 99% of the time, had unprotected oral sex. (HIV-uninfected, internet escort)

Condom Use Related to Earning Potential The majority of participants reported being offered more money to have unprotected sex. However, internet escorts often reported turning offers down:

I have had a client ask me and I had to turn it down. I can’t do the unsafe sex thing. I mean there have been times I’ve thought about doing it…like one time I had a large amount, like $350, and I told him yes at first, then I said you know what, I can’t without a condom because you know I can’t. I have to have a condom. (HIV-uninfected, internet escort)

In contrast, street workers reported engaging in unprotected sex when offered more money out of desperation and need for money/resources:

Using no condoms is going to put more money in your pocket. And the more money in your pocket, the less chance you got to deal with another dude…that’s like an extra 50 or 100 bucks right there. (HIV-uninfected, street worker)

HIV Status and STI History

Nearly one third (31%) of the sample reported being HIV-infected and 28% reported having been diagnosed with an STI at some time in their lives (16% gonorrhea, 6% chlamydia, 9% other [e.g., HPV, Hep-C, HSV], 3% syphilis). Strikingly, one fourth of the sample had never been tested for STIs.

Two street workers reported having become HIV-infected in the context of doing sex work:

Yeah, from prostitution, ’cause I never had it—before I had a lover and I didn’t have it then. Then in about 1997 I started hooking, so I got it from somebody—passed around but didn’t know. [I would get] high and didn’t really know about condoms, you know. (HIV-infected, street worker)

Disclosure of HIV Status Most HIV-infected participants reported that they usually disclose their HIV status to sex paying partners:

I do because I’m up front. I’ve got the virus. I’m not out to kill anybody, and I get that argument too. Well honey, I got it too, you don’t need that [condom]. I says well, I don’t know which strain you got. (HIV-infected, street worker)

Several HIV-infected participants, however, felt that people need to take responsibility to protect themselves and their own health and that it is not necessarily the responsibility of the HIV-infected person or the sex worker to have to initiate the HIV/STI discussion:

You should assume that anybody’s positive, but especially a sex worker. I kind of let everyone take responsibility for themselves. Because I do and I did and, so I usually don’t tell them unless they ask or if they seem like they’re really concerned about it, even if they haven’t asked me directly, and I can tell that they want to know, I’ll tell them. Like, my weekly regular never asked me if I was positive, he asked me if I was safe and I said yes. (HIV-infected, internet escort)

Barebacking Several HIV-infected participants talked specifically about “going raw” or “barebacking” in the context of sex work, all of whom were internet escorts:

If we meet and he wants to fuck me bareback and I’m like he’s pretty hot, then yeah, I’ll say OK. (HIV-infected, internet escort)

Motivations and Reasons for Doing Sex Work

Participants’ motivations and reasons for doing sex work differed by recruitment type and were consistent with observed demographic differences.

Financial The most commonly reported motivation or reason for having engaged in sex work in the past 12 months for all participants was financial. However, differences were observed when looking at street workers vs. internet escorts. Street workers commonly reported having engaged in survival sex, that is, exchanging sex for basic necessities including money, food, housing, a “place to stay for a couple of nights,” and paying bills:

Living in the streets, you’re fucked. You know, you can’t go into the kitchen and make a peanut butter and jelly sandwich, and shelter food is disgusting…So what do you do? You can get pretty for day, make a few phone calls, walk around the block. Some guy’s going to take you out for the steak lobster dinner, put you in their bed for the night, and give you money, so you could keep going and shower and stuff like that. You know, if it wasn’t for some of them, I don’t even think my cell phone would have been on half of the time. (HIV-uninfected, street worker)

One street worker discussed having done sex work while in prison, describing having exchanged other survival necessities specific to the context of jail, namely, having sex for friendship or protection:

You trade off for things other than money. You know, just like friendship, or stuff like that, it’s a little more basic stuff…There’s guys that will look out for you. (HIV-uninfected, hepatitis C-infected, street worker)

Street workers commonly used the words “desperation” and “survival” in explaining their reasons for doing sex work, describing their need for “the basics” to simply “get by” from day-to-day.

In contrast, internet escorts recruited online often reported the “lucrativeness” of sex work as being their main financial motivation, referring to it as an “easy” way to make a good living or some extra supplemental income:

I see it as a profession; it’s a career that I spend time and money on. I kind of take it seriously…I kind of feel like, even though it’s not something I want to be doing forever, I feel like I’m turning it into a positive thing—a career. (HIV-uninfected, internet escort)

Several internet escorts who were students described engaging in sex work because they needed money for school:

It really is great not having to work, and to get to do this, like it allows me to do my college work without having to worry about taking a part time job which I would have to otherwise. (HIV-uninfected, internet escort)

Drugs and Alcohol Drugs and alcohol were often mentioned in the context of describing motivations for sex work. Among street workers, supporting a drug habit figured prominently as a motivation and reason for doing sex work. As one participant put it, “It seems like the prostitution world is drugs.” Most commonly, street workers reported sex work for money to buy crack and/or cocaine:

I think if I quit coke, I probably wouldn’t be doing it. Really, because that’s why I do it, to get high. Any other money I make besides that, that I work for or I collect unemployment for, I buy food. I buy things. But that money, that’s my drug money. (HIV-uninfected, street worker)

While drugs also figured in for internet escorts, rather than doing sex work for drug money, they most often described drugs as being part of the sex work encounter, helping to motivate them by either making the encounter easier or helping them to lose their inhibitions. Most commonly, MSM recruited via the internet used crystal methamphetamine, G, and pot:

Especially when I would do G, I would lose my mind. Crystal meth and G, I would get into anything. [For example,] If a guy wanted to get into diaper scenes, if a guy wanted get into a scat scene… (HIV-uninfected, internet escort)

Several participants from both groups talked about the utility of drugs which allow them to perform in a sex work encounter where otherwise they may not be able to:

Sometimes you can’t perform for these guys without drugs, you know. Like, I wouldn’t touch you if I was sober so in most cases drugs come into it. Because you just can’t get it up and that’s the only way you’re going to pay your bills if you sleep with this guy, so you have to have a substance. Crystal meth was a great help in most scenes because it keeps you horny, or some of them will give crystal meth with Viagra so you can stay hard for them. (HIV-uninfected, street worker)

Excitement Excitement was described as a motivation for doing sex work. Several street workers cited “excitement” as a primary motivation for doing sex work, especially when describing the first time or their early sex work experiences:

I liked the experience, that I could be myself and not have to hide…I enjoyed it. It was like being on a rollercoaster. It was a rush. That’s the word I was looking for. It was a rush. (HIV-uninfected, street worker)

Power Several participants from both sex worker types reported feeling a sense of power or empowerment in doing sex work and having control over their choices and sexuality:

I think that because these guys are paying, you sort of have the upper hand sometimes. I don’t want to say I feel empowered by it—but I feel a certain sort of strong grasp on it. What I’m saying is that, you know, I say, ‘I made this conscious decision. This guy is obviously attractive. He’s attracted to me. He’s going to pay me. I’m going to use that. I’m going to enjoy it.’ (HIV-uninfected, Street worker)

A few internet escorts described feeling a sense of empowerment at a young age, particularly after first engaging in sex work. For example, in describing his first sex work encounter at age 17, one participant talked about how sex work was connected to feeling empowered about coming out:

To me it was just another kind of kink and I was just starting to explore my sexuality and so I was like, well that’s kind of interesting and different and it was kind of empowering too because I felt so like trapped at home and so this was a way for me to assert my sexuality I suppressed for so long and also have a little of my own money. And like then there’s the element of having—kind of power over these guys because they want you so bad. And, they’re willing to give you money for it. (HIV-uninfected, internet escort)

Others described how their physical attributes (young age, large penis size, etc.) made them feel noticed or a valuable “commodity” among men. For example, one participant described his first sex pay encounter at age 14:

I felt like such a rock star. I felt like finally I was putting my body to good use. And, you know, the other thing is for whatever reason, thank you higher power, gave me a really big dick. And so, that’s sort of been the appeal, I guess—because it’s kind of monstrous. (laughter) So, I think that’s part of what’s brought in the business, as it were. And I felt like, you know, I was being recognized. (HIV-uninfected, internet escort)

“Why not?” In discussing their motivations for sex work, internet escorts often said they would have sex anyway and preferred to get paid to do it:

The thing was, I was going to sleep with someone anyway, it might be for money, it might be for drugs; it might not be for anything at all but I was going to sleep with someone anyway, so I might as well try and milk it for all I could. (HIV-uninfected, internet escort)

Interestingly, no street workers mentioned this as a reason or motivation for engaging in sex work.

Friends and Social Norms Several participants, both street workers and internet escorts, talked about their reasons for sex work as being connected to friends or group social norms.

I have quite a number of friends who are transgender people, male–female, and this is what they do for a living, like a lifestyle, and I never really thought I would do it, looking at my background and where I’m from, never in a million years would I have thought that I would do it, but, I don’t know what kind of made me decide to do it, but I became really, really close with them, and I just put an ad out. (HIV-uninfected, internet escort)

Discussion

Findings from this study suggest that male sex workers who engage in sex with other men in exchange for money, drugs, housing, and other goods are a population at high risk for HIV acquisition and transmission. Inconsistent condom use was reported by both street workers and internet escorts with more than two thirds of the sample reporting unprotected anal sex with male sex partners of unknown or different serostatus in the past 12 months. In addition to increasing their own risk for acquiring HIV or other STIs, MSM who engage in sex work may also unknowingly infect their male and female nonsex work partners and serve as an important “bridge” population to intervene with.^5–7 Nearly one third of the sample was HIV-infected and the overwhelming majority of participants said HIV was not a topic of discussion in sex work encounters. Moreover, psychosocial and other risk factors, including substance use, depression, history of childhood sexual abuse, history of incarceration, and history of psychiatric inpatient hospitalization were frequently reported. Taken together, study findings suggest that HIV sexual risk behaviors among MSM sex workers are occurring within the context of intertwined syndemics^34,35 and likewise interventions need to incorporate these multiple risk dynamics in order to be effective.

Particularly relevant is the observed rate of childhood sexual abuse (41%) in this sample of male sex workers. Although similar to the rates found in other studies of MSM,^31,36–38 this finding is chiefly relevant for HIV prevention efforts because CSA rates among MSM are substantially higher than rates found in the general male U.S. population.³⁹ This is particularly concerning due to the damaging consequences of CSA that have been demonstrated specifically among MSM, including mental health hospitalization, psychoactive substance use, depression, and suicidal thoughts or actions.

Consistent with prior research,^10,11 noteworthy differences in sexual risk and condom use were observed by sex worker type. The majority of participants reported being offered additional money by sex work partners to have unprotected sex at some time in the past. However, internet escorts often reported turning down offers to have unprotected sex for extra money. Street workers, on the other hand, reported engaging in risk behaviors with sex work partners for more money out of financial desperation—demographically, street workers had lower levels of education, reported greater unstable housing, and were often unemployed or disabled relative to internet escorts. The finding that street workers engaged in riskier sexual activities for more money is consistent with research documenting that street workers report highest rates of HIV risk behavior relative to other types of sex workers.^5,12–14,21 In contrast, many internet escorts reported increased HIV sexual risk-taking among casual or recreational sex partners relative to sex work partners, a finding that is also supported by prior research.^15,16

Motivations for engaging in sex work included financial, drugs/alcohol, excitement, power, “why not?,” and friends and social norms. Many internet escorts talked about how they would have sex anyway and so may as well get paid to do so (“why not?”) in describing their motivations; this is supported by the finding that internet escorts reported higher mean numbers of male sex partners and transactional sex work partners in the past 12 months. Street workers commonly reported engaging in sex work for drugs and reported higher frequency of crack and cocaine use during sex in the past 12 months than internet escorts. Internet escorts described feeling a sense of empowerment at a young age, particularly after first engaging in sex work and how their physical attributes (young age, large penis size, etc.) made them feel noticed or a valuable “commodity” among men. These factors could be influenced by social stigma, social support, and poor self-esteem—future studies should attempt to understand this interplay between HIV risk and possible protective factors among MSM sex workers.²²

Several noteworthy limitations bear mention. First, HIV serostatus was self-reported by participants. Because the study team did not conduct HIV confirmatory testing to verify participant self-report, participants may have potentially been unaware of having seroconverted since their last test or it is possible they had not been tested for HIV at all. Second, survey data did not separate sexual behavior by partner type (e.g., transactional sex vs. nontransactional sex). Third, the nonprobability sampling method employed means the possible introduction of sampling bias, a less representative sample of the population, and limited generalizability of results. For example, biases may have been introduced because some recruitment occurred at FCH, which could result in the sample having a higher prevalence of HIV than MSM in the Boston area. Finally, even though qualitative interviews reached redundancy in responses, the MSM sex workers interviewed in this study comprise only a specific subset of all MSM sex workers at risk for HIV, and thus further generalizability of results may be limited.

Limitations notwithstanding, study results indicate that the contextual and psychosocial issues, including substance abuse, surrounding HIV risk behaviors and condom use among MSM who engage in sex work are varied. These findings can be used to generate hypotheses for designing and providing tailored primary and secondary prevention interventions for this at-risk subgroup of MSM. Interventions must address the “intertwined syndemics”^34,35 related to sexual risk-taking in order to be effective with intervening on the complex and multifaceted issues associated with HIV risk behavior among MSM sex workers.