“In different situations, in different ways”: Male sex work in St. Petersburg, Russia

Abstract

We conducted a qualitative study of male sex work in St. Petersburg Russia with a focus on social vulnerabilities, HIV risk perception, and HIV-related behaviours. In-depth interviews were conducted with individuals knowledgeable about male sex work through their profession (n=8) and with male sex workers themselves (n=12). Male sex work involves a variety of exchanges including expensive vacations, negotiated monetary amounts, or simply access to food. Methods to find clients included the Internet, social venues (e.g. gay clubs and bars), and public places (e.g. parks). Use of the Internet greatly facilitated male sex work in a variety of ways. It was used by both individuals and agencies to find clients, and appeared to be increasing. Men often reported not being professionally connected to other male sex workers and limited disclosure about their work. Many were aware of the work-related risks to personal safety including violence and robbery by clients. Perceived risk for HIV was mostly abstract, and several exceptions to condom use with clients were noted. Alcohol use was reported as moderate but consumed frequently in association with work. These data suggest that the most salient risks for male sex workers include professional isolation, threats to personal safety, limited perceived HIV risk, and sub-optimal levels of condom use.

Introduction

The HIV epidemic in Russia is largely concentrated among injecting drug users (IDU) and the subset of female sex workers who use drugs (UNAIDS 2009) with prevalence estimates approaching or exceeding 50% (Niccolai et al. 2010; UNAIDS 2010; WHO 2004). The estimated national adult HIV prevalence exceeds 1% (UNAIDS/WHO 2009), and the increasing proportion of new cases attributed to sexual transmission (Pokrovsky et al. 2011) raises concern about the potential for transmission beyond these known high-risk groups to a more generalised epidemic (Lowndes et al. 2003; Niccolai et al. 2009a). Little is known about the likelihood of HIV transmission among male sex workers, another potentially important vulnerable population.

The social, economic, and political changes that accompanied the transition in post-Soviet Russia were unprecedented, widespread, and accompanied by an increase in different forms of sex work (Atlani et al,. 2000). This proliferation was in part an adaptive response to loss of previous income and facilitated by changing social norms that increased the supply side for sex work (Levina et al. 2012). Despite this, sex work occurs largely in an environment of intolerance, stigma, and moral public attitudes. Legally, sex work is an administrative offence for which individuals can be fined.

A growing body of research has been conducted on sex work in post-Soviet Russia. Studies conducted during 1999–2002 using qualitative and rapid assessment methods reported on the context of female sex work in St. Petersburg (Aral and St. Lawrence 2002; Aral et al. 2003; Aral et al. 2005), Moscow (Aral et al. 2003), and Saratov Oblast (Aral and St. Lawrence 2002). These studies revealed both similarities and differences across the regions. In all three locations, female sex work was described as occurring in various ways including exclusive escort services, agency-based including use of the Internet, venues including hotels, massage parlours, and brothels, and public locations including street, railway and train stations, and truck stops. The hierarchical nature of female sex work was also described, with a more elite group of women working for escort services and in five-star hotels and the most economically vulnerable women working in public places. Female sex work in St. Petersburg was described as `ubiquitous'. Street-based female sex workers are often drug-involved. A variety of types of agencies exist to facilitate female sex work ranging from publicly advertised escort agencies to “marriage” agencies involved in trafficking. Brothels often operate in large apartment buildings. Virtual Internet brothels are another type of agency in which potential clients can go to specified websites and arrange the service online. In Moscow, female sex work was described as more organised with frequent involvement of pimps and assistants including drivers, assistant female pimps, guards, and recruiters. Female sex work in Moscow is also linked to internal and external migration of women and their clients. In all three areas, these studies revealed little about male sex work. In Moscow, it was noted that male sex work is similarly hierarchical and often club-based in well-known districts. In St. Petersburg, male sex work was reported to occur less frequently than female sex work and typically though agencies, Internet brothels, or public locations.

Another study also conducted over a decade ago similarly revealed the presence of male sex work in St. Petersburg. In 2000, 434 men who have sex with men (MSM) were interviewed, of whom 23% reported having sold sex for money or other valuables (Kelly et al. 2001). Risk behaviours were high in this group, with a median of three sex partners in the past three months, 45% reporting unprotected anal intercourse past three months, and 33% reporting a past sexually transmitted infection. Male sex workers were more likely to be unemployed, less well-educated, and report not having enough money to buy condoms. Despite this literature documenting the existence of male sex work in Russia, limited research has followed. We are aware of only one study that specifically targeted this population. A pilot study of male sex workers was conducted in Moscow during 2005–2006, in which 50 men were recruited through venue-based and snowball sampling methods (Baral et al. 2010). Results of a structured survey were suggestive of a myriad of risks related to migration status, violence, substance use (predominantly alcohol) and sexual behaviour. Furthermore, serological testing showed an HIV prevalence of 18% (9/50). Among MSM in St. Petersburg, HIV prevalence has been estimated at 5%–7% (Amirkhanian et al. 2009; Baral et al. 2012; Niccolai 2009b). It has also been observed that high frequencies of multiple sex partners, unprotected anal intercourse, and transactional sex place them at substantial risk for HIV infection (Baral et al., 2012). Clearly, additional information about the vulnerable population of male sex workers is needed to better understand the broader context of these risks.

As a group that emerged after the collapse of the Soviet Union, civil society has had limited interaction with MSM including male sex workers. Targeted outreach activities for MSM that exist in Western Europe, North America, and Australia are relatively rare in Eastern Europe. Recent activities in Russia indicate little support for MSM. A new law in St. Petersburg outlaws activities that are seen as promoting homosexuality to youth in public places (Statute 273–70 “Regarding administrative offences in St. Petersburg”, Article 7.1 Public actions aimed at promoting sodomy, lesbianism, bisexuality, transgenderism among minors). Individuals have already been fined for this administrative offence, raising concern about the law being used to prevent social actions to support MSM (AFP 2012; Schwirtz 2012). This law has been described as discriminatory by the United Nations Human Rights Committee (Human Rights Watch 2012a). Furthermore, the European Court of Human Rights found Russia in violation of permitting free assembly for denying activists the right to hold gay pride marches (Human Rights Watch 2012b). This environment may increase their stigmatised and marginalised social status raising concern about violence that male sex workers may experience related to their work (Scott 2005). Additionally, because the link between male sex work and HIV risk has long been recognised (Aggleton 1999), it is troubling that Russia recently lost eligibility for financial support from the Global Fund to Fight AIDS, TB and Malaria because of its high income status (USDHHS 2012), and it remains unclear whether support from the federal government will be forthcoming. The Russian federal HIV prevention plan is largely focused on promoting healthy lifestyles in the general population and allocates limited funds for prevention activities directed at the most at-risk populations (USDHHS 2012; The Lancet 2009). Because of this situational context and the varied nature of male sex work (Browne and Minichiello 1995; Minichiello et al. 2001; Nureña et al. 2011), we felt it was critical to extend our knowledge of the social context of male sex work in Russia.

We conducted a qualitative study about male sex work in St. Petersburg to describe the following: (1) characteristics of this population including methods and locations for meeting clients; (2) social vulnerabilities related to this work; (3) HIV risk perceptions, and (4) behaviours related to condom use and substance use. This collaborative project was a partnership between a non-governmental organisation (NGO) in St. Petersburg with over a decade of experience conducting HIV outreach and prevention research for vulnerable populations and investigators from the USA.

Methods

Data were collected in St. Petersburg, Russia between February–June 2011. St. Petersburg is the western-most city of Russia and has approximately 4.5 million residents. In-depth interviews were conducted both with individuals knowledgeable about male sex work through their professions (referred to as `professionals' in this manuscript) and male sex workers. First, individuals familiar with the target population through their professional work were recruited through known contacts of project staff, peer referrals, and direct outreach. Targeted sampling ensured recruitment of staff from service organisations (e.g. non-governmental organisations) and social venues specific for MSM (e.g. gay clubs). Eligibility criteria included working for an organisation that had contact with the population of interest (male sex workers) and willingness to participate; engaging in sex work or being an MSM were not required for participation in this part of the sample. Male sex workers were subsequently recruited through known contacts of project staff, peer referrals, and the Internet. The eligibility criteria for male sex workers included willingness to participate in a study seeking to recruit men who were engaged in sex work; this term was not further defined. Internet-based recruitment was conducted by sending e-mails to men advertising the sale of sex on a bulletin board website. Messages contained a brief description of the study. Men who were interested could then respond to set up the interview. Participants provided written informed consent and were offered 1000 roubles (~30 USD) for their time. This study was approved by institutional review boards at St. Petersburg State University and Yale University.

All interviews were conducted in Russian. Separate interview guides were developed for professionals and male sex workers. Both guides contained questions about similar key topics related to male sex work including scope, types, social organisation, locations, personal safety, perceived risk for HIV, condom use, and alcohol and drug use. Interviews with professionals also included questions about how best to recruit male sex workers for this study. Interviews were conducted by three members of the research team (2 Russian, 1 US), audio-recorded, and transcribed verbatim. Interviews lasted approximately one hour (mean = 61 minutes, median = 54 minutes). Translation of quotes was done by both Russian and US investigators fluent in their non-native language.

Thematic coding of transcripts was primarily descriptive and based on established methods (Miles and Huberman, 1994). An initial codebook was developed with a priori (deductive) codes based on the research questions and applied to a subset of the interviews by three members of the research team. Using an iterative process, the codebook was revised after discussions of transcripts and discrepancies, and it was subsequently applied to each interview by all three investigators. Code reports were generated containing narrative on emergent themes and discussed by members of the research team for synthesis and corroboration of results.

Results

Participants

Eight professionals (out of 11 attempted contacts) and 12 male sex workers (out of 18 attempted contacts) participated in this study. The 20 participants are described in Table 1. The one participant who reported selling sex to women only was excluded from these analyses to permit a consistent focus on men who sell sex to other men. Each participant was assigned a code for linking with quotes throughout the manuscript; names used are pseudonyms.

Table 1.

Study participants

Code	Respondent characteristics	How recruited
NGO1	Senior management of HIV NGO	Known by research team
NGO2	Researcher	Known by research team
NGO3	Senior management of MSM NGO	Organisation's website
NGO4	Senior management of MSM NGO	Peer referral
NGO5	Outreach worker with HIV NGO	Peer referral
CLUB1	Owner of cruising club	Peer referral
CLUB2	Manager of gay club	Known by research team
CLUB3	Manager of gay club	Peer referral
MSW1	Male sex worker, age 21, non-regular sex work	Known by research team
MSW2	Male sex worker, age 24, street-based	Known by research team
MSW3	Male sex worker, age 31, escort	Known by research team
MSW4	Male sex worker, age 30, female clients	Known by research team
MSW5	Male sex worker, age 20, escort and Internet clients	Internet
MSW6	Male sex worker, age 18, Internet clients	Peer referral
MSW7	Male sex worker, age 22, known contacts	Peer referral
MSW8	Male sex worker, age 27, escort	Peer referral
MSW9	Male sex worker, age 25, Internet clients	Internet
MSW10	Male sex worker, age 22, Internet clients	Internet
MSW11	Male sex worker, age 18, Internet clients	Internet
MSW12	Male sex worker, age 27, Internet clients	Internet

Patterns of male sex work

Male sex work was reported to be a practice that “happens a great deal” (Ilya, aged 31, MSW3) and “everyone is ready to take the opportunity” (Sergei, aged 27, MSW12). It was also noted that the scope of male sex work depends on what constitutes the exchange with sex for clothes, meals in restaurants, or gifts instead of money being “far more common” (Dmitry, age 27, MSW8).

Yes, sex is sold for money all the time. Sex for clothes, too. It is not that it is exactly prostitution…It is a common practice. People meet up with each other, and someone buys someone clothes. And that is it. (Anatoly, age 21, MSW1)

Types of male sex work emerged according to locations for arranging and negotiating sex work, including recruitment of clients on the Internet, though organised agencies, at social venues, and in public spaces. Several websites were mentioned that facilitate male sex work: “there might be 20 addresses, I do not remember them all” (Ivan, NGO1). Many websites were dating sites where men can either indicate that they are interested in finding sex partners who will pay them (e.g., clients) or this can be discussed after communication has been initiated. The use of message boards was also commonly reported where individuals post advertisements to which potential clients can respond electronically.

(Interviewer: Where do individuals find clients?) The Internet – definitely. The wall on [name of website]. And dating sites, sometimes you admire someone's appearance, you write him a compliment, and he replies: `I am 5000 roubles for 2 hours'…On [name of website] website, a profile highlighted in pink means he is offering sex for money. And those who surf the Internet pay attention to it. (Sergei, age 27, MSW12)

I submit the advertisement on the Internet…And I write up front, why I need this meeting. It is specified up front that it is sex for money or something else… They already know what this is. And they already want it. (Nikolai, age 22, MSW7)

The ease of finding clients via the Internet was cited as a reason for its increased use: “Since the Internet became widespread [for meeting sex partners], club culture has become more a social place than a hook-up place.” (Peter, NGO2), “If it [sex] is for money, then it is mostly through the Internet. There it can all be negotiated up front and where messages are exchanged.” (ditto), and “In general, prostitution is not happening in the clubs, it is on the web.” (Andrei, CLUB1). The Internet was also noted to facilitate male sex work by making connections in different cities (e.g. Moscow). Others noted that the Internet also facilitates finding gay clubs where sex is sometimes sold: “(Interviewer: And where does the information about this [clubs] come from? The Internet?) Of course, the Internet.” (Anatoly, age 21, MSW1)

Agencies that were most often described operate virtually through websites. Advantages and disadvantages of working through an agency rather than individually were frequently mentioned. One disadvantage included limited control over decision making about which clients to accept and when. “The disadvantage is that they are stripped of their rights to choose.” (Maxim, age 18, MSW11). Another disadvantage is the proportion of income, typically half, that must be paid to the agency. Advantages included not having to look for clients and some degree of protection for personal safety. One respondent reported being approached to work for an agency but declining (Oleg, age 25, MSW9), another reported working both with an agency as well as individually (Dmitry, age 27, MSW8).

The agency has constant orders. There's a fixed rate, like it or not, a client doesn't barter with an agency. You go to the website and there are two boys, three to five thousand (roubles) for an hour. Minimum order is 2 hours. He takes 6,000 from the client, and gives 3,000 over to the agency and keeps 3,000 for himself…But on the other hand, an individual can find his own clients for 3,000 and can get everything done in an hour and not have to work those two hours like in an agency. (Sergei, age 27, MSW12)

Only a Moscow-based (pimp). But I have never seen him. He calls me and says `There is such and such a person, and you need to go to the hotel.' His agency is in Moscow. He added me on the Internet himself…He found me himself, made an offer, and I agreed to try it… they call him, and then he either gives me the phone number or tells me where to go. (Anton, age 20, MSW5)

Social venues in St. Petersburg were frequently mentioned and include gay bars, a cruising club, and saunas. Several well-known and visible gay bars exist in St. Petersburg in which transactional sex reportedly occurs. Multiple respondents could easily name the same clubs. The clubs range from elite gay clubs with entertainment events to clubs that are known to have more of a commercial sex purpose: “[Club name] is more for commercial purposes. There is a dark room there. And one can simply have sex there. Those who want to have sex.” (Nikolai, age 22, MSW7) Though these clubs do not exist primarily for transactional sex and some respondents mentioned that payment for sex in these venues is prohibited, they do facilitate the meeting of sex partners ranging from romantic relationships to anonymous sex, and may include varying elements of exchange including either drinks or money.

In clubs, it happens rather disguised, so to speak, no one is standing or sitting there with a sign that says `I'm selling sex services'. But this is a crowd of regulars… They already know everything, and they simply get acquainted with men with whom they think might be interested in their services, make contact with them, chat with them, and in one way or another make it clear that they are not against getting remuneration. They may say, `You know, I don't have any money right now', `could you help me out', and so forth. (Iosef, NGO3)

Foreigners come to see what Russian guys are like. Sometimes foreigners come in and ask directly if they can hire a guy. We can't give them a concrete answer, but I tell them to try, that maybe something will work out. (David, CLUB3)

“I, of course, understand that some of the young people are doing this. If I sit down and observe for awhile, then I can make some assumptions…I watch how people communicate, make arrangements.” (Stanislav, CLUB2)

Saunas were mentioned as a venue where male sex work may occur. Russia has a long history of saunas or banya that are used by many people (e.g. families, friends, business partners) to relax, bathe, and improve health with no sexual context. However, there are some saunas that do provide an atmosphere for sexual activity, including sex work. Saunas in St. Petersburg known to be `gay saunas' that are exclusively by MSM reportedly serve as a location for male sex work. Another venue that was mentioned was a well-known cruising club that exists primarily for the purpose of meeting anonymous sex partners. Saunas and the cruising club are more hidden from public view than the gay bars.

There is a sauna. The gay sauna. There is a sauna in [location] with a theme a week…There is [another] sauna, on [different location], the largest sauna. There hangs a large sign that this is a [different type of venue], but when a customer approaches and starts ringing the bell… everything is understood.” (Anton, age 20, MSW5)

In my case (the introductions with clients) took place at a club. (Interviewer: So everything is clear at once? Does he bring you some alcohol?) Yes, and definitely not the cheapest. This is not beer or vodka…this is an opportunity to show generosity…At [club name] there are several toilet stalls, where there are holes in the wall at below waist-level. There are several mazes, where all this can happen…(These clubs suggest that sex there is possible?) The clubs suggest this. But [club name] is simply a place exclusively for sex… There is not even music. Only pornography on the screens. (Anatoly, age 21, MSW1)

Men working in a pleshka (an outdoor space where men meet other men for sex including transactional sex) were described as the most economically vulnerable group: “a very disadvantaged group” (Peter, NGO2) and “cheap boys who work for a piece of bread” (Pavel, age 24, MSW2). They are often homeless and of very young ages, sometimes 14 or 15 years of age. One particular pleshka was frequently mentioned as being a well-known location for male sex work. Because of this reputation, individuals approach each other to offer or request sex: “They (clients) already know where and whom to approach” (Pavel, age 24, MSW2). Encounters in these settings are typically with one-time, anonymous clients and described as “short-term sex”. Sex workers may find both local and foreign clients in public places, and some of the men working in these locations are internal migrants themselves (including one respondent who was Russian but not from St. Petersburg and worked in the well-known pleshka). An NGO worker (Konstantin, NGO5) reported that some of the men (including underage boys) working at the railway station were dependent on heroin.

One must understand that this place (pleshka) is for the lowest of the low. That is, those who come from other cities, regions and are waiting for their prince on a white horse, and are sometimes willing to put out for a cup of soup. (Ivan, NGO1)

People work for themselves. They come and sit on a bench. In the summer they sit on benches, and in the winter they circle the place on foot. This is a place for sex services, basically. (Pavel, age 24, MSW2)

The volume of sex work in these locations is uncertain and several respondents noted a preference not to work in pleshkas if other options were available.

If a person has housing and he has a computer, then he certainly will not go onto the street. Well, with rare exceptions.” (Iosef, NGO3)

“There is such a place, (well-known pleshka). But who is there now? Those who have no access to the Internet – the lowest stratum.” (Dmitry, age 27, MSW8)

Our clients are not there, rather, they are there, but only periodically. This is due to the fact that there are now quite a large number of clubs where they can go.” (NGO4)

As far as I know, earlier, that might be true, that at the Moscow Railway Station, boys were constantly coming up and offering some fun in the toilet. I think that they were younger than 16 years old. But over time this community has been eliminated…most likely by law enforcement agencies. (Anatoly, age 21, MSW1)

Another type of sex work that emerged was described as a “marriage of convenience” and could not be easily classified by location of client recruitment. One male sex worker (Ilya, age 31, MSW3) described a relationship with a “wealthy gay” man who took him on expensive vacations and bought him clothes and shoes, “all I want…literally everything”. This relationship began as a personal acquaintance that evolved into exchange sex. This client provided referrals for future clients when the relationship ended: “he suggested friends”.

It is not necessary to go to an escort agency for this. There are fairly nice-looking guys, who know their own worth. If you approach him with an offer, they say `If you want to be with me, I cost 300,000 [roubles] per month'. (Sergei, age 27, MSW12)

Social vulnerabilities

Social vulnerabilities that emerged include limited disclosure of identity and work, lack of appropriate health and social services, and threats to personal safety. Many male sex workers have a gay identity and are therefore members of “one of the most closed groups of Russian society” (Iosef, NGO3), making this a difficult topic for some to discuss. Some men reported revealing their gay identity to family or friends but not their involvement in sex work. There were varying levels of discussion about involvement in sex work with peers. Some reported knowing others involved in sex work and some reported knowing few others or no one.

(Interviewer: If you go to a doctor for any reason, do you say you provide sex services?) No. (Interviewer: Why do you keep it a secret?) I am ashamed, embarrassed. They do not understand. (Interviewer: And what about having sex with men?) That I do not hide. My parents are fine about this. My mom, dad, and sister. (Interviewer: Do you tell them about sex work?) That I cannot say because there will be trouble. (Pavel, age 24, MSW2).

I know one [other male sex worker]. But as a rule, we are all trying to work alone, not make friends. (Pavel, age 24, MSW2)

I do not have any acquaintances whatsoever who work for money. I do not ever mention this to anyone. This is something that lives in me and this will never be anyone else's business. (Sasha, age 22, MSW10)

Disclosure of sexual identity and involvement in sex work to health care providers was very limited. Negative attitudes from health care professionals were frequently anticipated or reported: “After she drew my blood, she washed her hands in such a way, that it really made me feel like something that is laying around the toilet.” and “I openly said I was gay. Lord, it was such homophobia.” (Mikhail, NGO4)

A huge problem is, of course, again due to the hidden community, that in the majority of regions in Russia there are no special services, no legal counseling or psychological services for gay, lesbian and transgender people. But on the other hand, most of them are terribly afraid to contact the police if something happens to them. They are terribly afraid to go the doctors if they are having any health problems, if those are related to their sexuality. (Iosef, NGO3)

(Interviewer: Do you discuss that you work in sex services when seeking medical care?) No. This is ruled out. Once I went to a private clinic and a young, well-groomed guy was before me in line. And the doctor simply kicked him out. And that was a private clinic. I can't know for sure what happened there, but I try to hide it all. Because everyone has their own prejudices. (Interviewer: And do you also do not tell the doctors that you are gay?) No, I do not tell them. (Ilya, age 31, MSW3)

Regarding interactions with clients, respondents were generally aware of the threats to personal safety. The concerns that were raised were mostly related to robbery, violence, and group theft by clients. Respondents reported both personal experiences with violence by clients in addition to being aware of this happening to other male sex workers. Though some reported that increased protection was an advantage of working for an agency as opposed to working alone, others questioned the extent to which this was actually true.

I have one friend who was robbed. He met a boy at a gay club, got drunk, and brought the boy to his place. The boy gave him some kind of pills that put him to sleep, and the boy took 1,000 roubles from him. A credit card with the PIN-code was also in the bag. (Nikolai, age 22, MSW7)

Yes, sexual violence and nonsexual violence. They [clients] could simply just beat someone up. Moreover, it is often a question of sexual practices. Many customers believe that `he who pays, orders the music' and the person who he pays has to do everything that he is told, no one asks his opinion…Violence perpetrated by clients is a very important issue. (Iosef, NGO3)

If you are working alone, then they might throw you in the car, f**k you as hard as they can, and toss you out on the sidewalk. And then the guy has to get home anyway he can. Especially, if he doesn't have any money at all, and he just came to earn some. These kinds of things also happened. (Anatoly, age 21, MSW1)

Men used a variety of strategies to minimise risk, including refusing clients based on character judgments or previous communications on the Internet, meeting clients in apartments or hotels instead of cars, collecting payment prior to sex, working in the daytime, minimising alcohol use, and bringing friends.

There were some unpleasant situations. But, when I invite the person to my place, I at least know that one person will come. But when you go there, there may be a group of five. And you will leave, even without any money. Just to get out alive. (Sasha, age 22, MSW10)

We agree to meet at some place outside so that I can check and see if the person [client] is shady. I just go up to him and start conversation, and if right away I see any aggressive actions, or I get a negative vibe about him just by chatting, then I just turn around and leave. I try to pretend that I was never even there….I'm a fairly good judge of people. (Boris, age 18, MSW6)

HIV/STI risk perception and behaviours

Perceived risk for HIV was almost universally reported among the male sex workers but in an abstract way: “the risk is always there” (Dmitry, age 27, MSW8). One professional reported that HIV is a “distant threat” for many male sex workers, and male sex workers reported awareness of HIV from sources such as Santa Barbara (a soap opera) and the death of Freddie Mercury (rock star). Many respondents acknowledged their risk for HIV by often citing that condoms are not 100% effective at preventing transmission, yet there was limited discussion of specific personal risk behaviours. Furthermore, only a small number of the men reported knowing anybody who was HIV-positive.

Of course there is [risk for me to get HIV]. Even condom manufacturers do not provide a 100% guarantee that during sex the condom will not burst, slip, or break. (Anton, age 20, MSW5)

Certainly [there is personal risk for HIV infection], but up until now… touch wood'. (Ilya, age 31, MSW3)

All men reported using condoms (“in theory, yes” (Ilya, age 31, MSW3)), but rarely were they used in all sexual encounters. Situations where condoms were not used included for extra payment, during oral sex, on impulse, with known clients, or with female sex partners.

(Interviewer: And if they offer a lot of money, but sex without a condom?) To be honest, this was the case several times. (Anton, age 20, MSW5)

Well, there was one such case, that we had sex without a condom. But this was not my first time with this person and we had a good relationship. I already understood that he was not sick with anything. So we tried it without a condom. But I always use a condom with those guys that I do not know. (Nikolai, age 22, MSW7)

I have had sex without a condom. There was so much passion, and such a crazy attraction, I understood that it was necessary to put on a condom, but nevertheless just thought `oh well'…Usually I have condoms with me, or the person has them. And if it turns out that we don't, then we go to the store. They are available. But unfortunately, there are times when you disappoint yourself and it is too late. (Sergei, age 27, MSW12)

Alcohol and other substance use

Drinking alcohol was frequently mentioned (“alcohol is everywhere” (Pavel, age 24, MSW2)) and often consumed with clients who were also drinking, though typically in moderate amounts (“not to get wasted, of course” (Dmitry, age 27, MSW8)). Being too drunk was considered a problem both for conducting work as well as for maintaining personal safety. Use of alcohol by respondents was primarily to relax and help with conversation and was often described in the club environment.

You come to the club… you take a shot of vodka for yourself. As we say, `a little vodka – for a light step'. Well, and also for courage. And you start looking for young men that appear to be well-off, that are more or less okay and don't suffer from some phobias, and you try to meet them. (Anatoly, age 21, MSW1)

I think alcohol is quite appropriate. Before the act, to relax, to create an atmosphere where people are more at ease. Especially when it's the first encounter, when you see a person for the first time, so that you can have closer communication …. I think wine is enough. (Interviewer: And, hard liquor – vodka, cognac?) I think it's unnecessary. (Boris, age 18, MSW6)

Boys who come to us from the `outdoor cruising sites' had problems with alcohol. There were some that used drugs, but these were isolated cases. Mostly, they were drinking all kinds of junk, especially in the clubs. (Mikhail, NGO4)

Current hard drug use was not reported by any respondents though a small number reported prior use that was described mostly as experimental. Nitrites, commonly referred to as poppers, are recreational club drugs used to enhance sexual pleasure and were often mentioned. Use of poppers was typically not self-use but rather use by client: “I know that there are a lot of things out there, for example poppers. But I don't need them.” (Maxim, age 18, MSW11). One hard drug that was mentioned was cocaine, with use being either by the client or past experience by respondent.

It is obvious why women are working the streets: they work for the sake of a dose, earning money for a dose is at the top of the list, and then everything else. There are those among the men who work the streets that are there for the dose, but I don't think that the percentage of drug users among MSM is that high. (Ivan, NGO1)

I do not use drugs. There are a very few clients who use cocaine. It is relatively rare that they use poppers to enhance orgasms or to relax. But I have not tried them, and I have not tried cocaine. I am the kind of person who can easily get carried away, so it is better to not even try. (Dmitry, age 27, MSW8)

I used cocaine once. But that was a long time ago. And I said to myself that that's it, if a client suggests cocaine, I will just turn around and say `goodbye'. I now dictate the conditions and they are drug-free. (Ilya, age 31, MSW3)

Discussion

Male sex work in St. Petersburg, Russia can be described according to how clients are found to facilitate discussion on the topic within this region. Understanding the nature of different venues is important as it may play an important role in the sexual risk for HIV and STI and their risk of violence from clients. Similar to female sex work, male sex work in St. Petersburg occurs in both organised and unaffiliated ways, and it spans the spectrum from highly paid escorts to men who work on the streets for subsistence. There also appears to be a hierarchy of risk, with those working on the streets being most vulnerable because of their poor economic and social standing.

Similar to other geographic locations (McFarlane, Bull, and Rietmeijer 2000; Nureña et al 2011), it is clear that the Internet has greatly facilitated finding paying sex partners in St. Petersburg in a variety of ways. For example, the Internet is used by both individuals and agencies and assists arranging commercial sex across broad geographical regions. The Internet offers advantages of being able to arrange a price ahead of time and to converse with a client, albeit virtually, prior to an in-person meeting. However, the Internet also allows men to work in relative isolation and may contribute to the lack of social cohesiveness among male sex workers (discussed further below). Our results also indicate that the Internet can be used to access this population for research, and by extension, possibly for outreach or intervention as well.

The lack of professional cohesion in the community of male sex workers points to an important potential vulnerability. Men often reported working alone and not personally knowing other male sex workers, even if they were open about their gay identity. Male sex workers may experience increased perceived stigma due to their gay identity and/or same-sex behaviour and their occupation. This manifests itself in limited disclosure to health care providers and possibly deeper feelings of isolation. Limited professional cohesiveness may also contribute to the limited awareness of HIV through lack of personal experience. Alternatively, the relatively low prevalence of HIV among MSM in St. Petersburg compared to injection drug users, estimated to be 7% and 45% respectively in a single study (Niccolai et al. 2009b) may signal that HIV is not yet a salient issue for this group. Either way, assessing HIV prevalence among male sex workers in St. Petersburg and the extent to which either general or personal knowledge of HIV increases or decreases their vulnerability are important for future research.

Alcohol use was commonly reported but in moderate amounts and typically associated with the club environment. It is difficult to say from these data if this pattern is substantially different from club scenes where non-commercial sexual encounters take place. Men typically cited using alcohol to help relax but limiting consumption as a means to protect personal safety and conduct work. Similarly, nitrites (poppers) were frequently mentioned but limited personal use was reported. Previous research showing associations between alcohol use (Shuper et al. 2010) and poppers (Drumright, Patterson, and Strathdee 2006) with HIV risk suggest that these risks warrant further study in this population.

One potential limitation of this study was not interviewing participants representative of the full range of male sex work. Informants acknowledged drug users being involved in male sex work but we did not interview any. In other settings, this group is particularly vulnerable (Vu et al. 2012). We only interviewed one person who reported working in public places and he was not recruited from this venue. We also only interviewed one migrant sex worker. It is known that people from other cities and countries face additional vulnerabilities due to not having city residency papers that provide access to health care services. Brief mentions of students, men in the military, and prisoners being engaged in sex work were made, but we did not interview anybody who fit these descriptions. We could not uncover the range or depth of vulnerabilities for each of these groups and therefore they all warrant further study. Alcohol and drug use may have been under-reported due to misperception of actual frequency or social desirability bias. Finally, this study was not designed to explore links between characteristics of male sex work and HIV risk; future studies should explore these issues. Despite these potential limitations, the data generated from this study are novel as male sex workers have not been qualitatively studied in St. Petersburg and therefore these findings contribute substantially to our understanding of this population.

Addressing the expanding HIV epidemic in Russia, a vast country that has shown limited response to date (UNAIDS 2009), will require a comprehensive approach that includes a better understanding of the potentially vulnerable population of male sex workers. For recruitment in future studies, the Internet may be a useful tool, but it is important to recognise that this method may miss some male sex workers and perhaps those at greatest risk. Vulnerabilities related to professional isolation, limited disclosure about their work, threats to personal safety, limited HIV risk perception, and suboptimal condom use should be explored in future studies. A better understanding of these risks can inform future prevention interventions and programmes.