Abstract
HIV prevention efforts must be comprehensive in their understanding of the factors involved in HIV risk. Male clients, who have received less research attention than female sex workers (FSWs), may experience stigma as a function of purchasing sex. Perceived stigma may be related to poor psychological outcomes, risky psychosexual characteristics, and higher drug and sexual risk behavior among male clients of FSWs. However, perceived stigma of purchasing sex may differ between clients of different ethnic groups. In the present study, we examine the correlates of perceived stigma of purchasing sex among Latino vs. non-Latino male clients of FSWs in Tijuana, Mexico. Using time-location sampling, we recruited 375 male clients (323 Latino, 52 non-Latino) in Tijuana who completed a computerized survey on various measures. We measured perceived stigma of purchasing sex using three items we developed for this study. Using linear regression analyses we found that perceived stigma was associated with greater guilt, a greater feeling of escape from everyday life, and more negative condom attitudes among Latino clients. This was not found among non-Latino clients. Features of Latino culture, like machismo, and how they may relate to stigma of purchasing sex are discussed.
Introduction
Female sex workers (FSWs) and often engage in high risk sexual and drug use behaviors, making them frequent targets of HIV prevention research and programs. Whereas FSWs have received copious amounts of research attention, less is true of their male clients (Patterson et al., 2009). Beyond health consequences such as HIV and sexually transmitted infections, for male clients, the act of purchasing sex is tied to legal and moral issues that may often bring about feelings of shame and a sense of deviance (Prieur & Taksdal, 1993). Male clients of FSWs may feel stigmatized, devalued, or discriminated against because of their behavior (Bernstein, 2008; Perkins & Lovejoy, 2007). In addition, because stigma is socially constructed, and because the experience of stigma is shaped by the multiple identities that people possess (e.g., ethnic identity), the experience and consequences of feeling stigmatized for purchasing sex may vary for different ethnic or cultural groups (Earnshaw et al., in press). This may be especially true when comparing Latino and non-Latino men because of different cultural norms regarding sex and sexuality (Marín, 2003). In the present study, we examine perceived stigma of purchasing sex as it relates to psychological, psychosexual, and behavioral characteristics among male clients of FSWs in Tijuana, Mexico. Tijuana borders San Diego, California and is experiencing rising rates of HIV concentrated among high-risk groups like FSWs and their male clients (Brouwer et al., 2006; Patterson et al., 2009; Strathdee & Magis-Rodriguez, 2008). A greater understanding of stigma, and how it might differ between ethnic groups, has implications for the development of socially and culturally-tailored HIV prevention programs for male clients of FSWs (Dana, 1998).
Stigma is classically defined as social devaluation associated with a “mark” or identity (Goffman, 1963; Link & Phelan, 2001). Stigma is socially constructed, and is ascribed to individuals who practice deviant behavior or behaviors that go against descriptive (i.e., how people behave) and injunctive (i.e., how people should behave) societal norms, like same sex relations, or drug use (Link & Phelan, 2001; Phelan, Link, & Dovidio, 2008). In general, perceived stigma, or the perceptions of societal devaluation and experiences of poor treatment, is associated with poor psychological outcomes, including lower self-esteem and more depressive symptoms (Branscombe, Schmitt, & Harvey, 1999; Jetten, Branscombe, Schmitt, & Spears, 2001). Whereas stigma research has focused on groups that include Blacks (Branscombe et al., 1999), homosexuals (Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008; Herek & McLemore, 2013), overweight people (Crocker, Cornwell, & Major, 1993), people living with HIV (Earnshaw & Chaudoir, 2009), and drug users (Semple, Grant, & Patterson, 2005; Semple, Strathdee, Zians, & Patterson, 2012), previous work has not examined perceived stigma of purchasing sex among male clients of FSWs. Patterns identified in the literature suggest that perceiving stigma because of purchasing sex may be associated with various adverse psychological and psychosexual characteristics, as well as drug and sexual risk behaviors among these men.
Cultural factors are important to consider when studying social processes like stigma. One characterizing feature of many Latino groups is the notion of machismo that designates men, and not women, as the strong, “macho” protectors of the family (Stevens, 1973). This gender role is also played in the sexual arena, with some men seeking multiple sexual partners, displaying dominance, and taking greater risks (Maansson, 2003). In addition, any Latino cultures hold strong conservative religious and family values. Therefore, compared to American culture and norms among non-Latinos in the U.S., Latinos are more likely to view sex conservatively (Marín, Tschann, Gómez, & Kegeles, 1993). Taken together, cultural pressures may have different implications for men who purchase sex and perceive stigma, depending on their ethnic background. For example, more conservative views about sex might be associated with greater perceived stigma of purchasing sex.
In the present study, we examine the correlates of perceived stigma of purchasing sex among Latino and non-Latino male clients of FSWs in Tijuana, Mexico. Specifically, we examined the relationship between stigma and psychological factors (e.g., self-esteem, depressive symptoms), attitudes about sex work, psychosexual factors (e.g., sexual compulsivity, sexual sensation seeking, stereotypes about male sexuality, and misogyny), and sexual and drug risk behaviors with FSWs. Given the cultural issues described above, we hypothesize that compared to non-Latino male clients Latino clients who report greater perceived stigma of purchasing sex will also report poorer psychological outcomes, higher scores on psychosexual factors, and more risky drug and sexual behaviors with FSWs.
Method
Participants and Setting
Participants were 375 male clients of female sex workers in Tijuana, Mexico. Tijuana is 20 miles south of San Diego, busy border crossing, sex work is quasi-legal in TJ but illegal in San Diego, therefore the red light district in TJ is a draw for both US and Mexico-based men. The current data are from the baseline assessment of participants enrolled in a HIV sexual risk reduction intervention that targeted male clients. Therefore, to be included in the study participants had to be HIV-negative adult males, report recently purchasing sex, and report recent (i.e., past 4 months) unprotected vaginal or anal sex with a FSW. Baseline data for this study were collected between September 2010 and March 2012. Participants were recruited from the zona roja in Tijuana. By design, half of the sample were residents of Tijuana (n=191) and half were residents of San Diego County, California (n=184).
Recruitment
To recruit participants we used time-location sampling within different colonias (neighborhoods). We have used this method in our survey and pilot work, and time-location sampling has been employed in other studies to recruit hidden samples of men who have sex with men, including Latinos (MacKellar, Valleroy, Karon, Lemp, & Janssen, 1996; Stueve, O'Donnell, Duran, San Doval, & Blome, 2001). With the help of outreach workers, we compiled a map of places where male clients of FSWs potentially frequented, including bars, brothels, shooting galleries, hotels, alleys and street corners. Trained outreach workers familiar with these establishments and their clientele approached prospective participants. Interested participants were directed to the research office in the zona roja (red light district) where they completed a screening questionnaire; a total of 678 men completed screening. Men who were eligible (n=412, 61%) and were interested in participating were given a study card and asked to present it when they visited the study office or mobile clinic. A small number (n=12) of participants who were eligible were not interested in being enrolled into the intervention. Reasons for not participating that were given to study staff included fear of the required blood draw, or not having the time to complete the entire study.
Procedure
Participants completed a survey in their preferred language (Spanish or English). The English survey was translated into Spanish and back-translated into English. Assessment occurred in the study office to avoid logistical problems in FSWs' workplaces. Men were reimbursed $20 USD or its equivalent for the interview, which took about 45 minutes to complete. All measures were administered using computer-assisted personal interviewing (CAPI; NOVA software, MD, USA). Written informed consent was obtained and participant anonymity and privacy were ensured during study procedures. All study procedures were approved by ethical review boards for human subjects research at the University of California, San Diego and our local participating institutions, the Tijuana General Hospital and Colegio de la Frontera Norte.
Measures
Demographics
Participants reported on their age, if they consider themselves Hispanic or Latino (yes/no), whether they currently lived in the United States, Tijuana, or another city in Mexico or the US, if they have ever been deported from the United States, their current marital status (married, separated or filing for divorced, divorced but not remarried, widowed but not remarried, never married, and common law), whether they had any children, their employment status, their religion (None, Catholic, Protestant, Jewish, or Other), and their sexual orientation (heterosexual, bisexual, homosexual/gay, or not sure). For the analyses, other than age each of these variables was dichotomized: Hispanic/Latino (yes/no), live in U.S. (yes/no), ever deported from the U.S. (yes/no), married/common law vs. all others, had children (yes/no), employed (yes/no), Catholic vs. all others, and gay/bisexual (yes/no).
Perceived stigma of purchasing sex
No No previous work has examined perceived stigma of purchasing sex. Therefore we used three items developed for this research, and are based on perceived stigma measures from other stigmatized identities (e.g., HIV-positive status); “People will treat me differently if they find out that I go to prostitutes;” “Most people look down on men who go to prostitutes;” and “Most people think that men who go to prostitutes are bad people.” Response choices were 1=strongly disagree, 2=disagree, 3=agree, 4=strongly agree (α = .78).
Attitudes towards and beliefs about sex work
Participants were asked to respond to the following items we developed for this research using a 4-point Likert type scale with 1= strongly disagree, 2=disagree, 3=agree, 4=strongly agree, “I feel badly about spending money on prostitutes;” “Having sex with a prostitute conflicts with my religious beliefs;” “I feel guilty about having sex with prostitutes;” “I feel guilty if I have unprotected sex with a prostitute;” “I feel badly for my (wife/steady partner) when I have sex with a prostitute;” “I worry that my (wife/steady partner) will find out about my going to prostitutes;” “It bothers me that I have a secret life of going to prostitutes;” “I get turned on when I think about getting caught with a prostitute;” “I get a thrill out of doing something ‘bad' like going to a prostitute;” “Going to a prostitute allows me to escape my everyday life;” “Going to a prostitute helps to fulfill my sexual fantasies;” “I like the danger associated with going to a prostitute;” and “I prefer to have sex with prostitutes in a setting where there is a risk of getting arrested.”
Psychosocial characteristics
We measured self-esteem, depressive symptoms, and perceived social support. Self-esteem was measured using the eight item Rosenberg Self-Esteem scale (Rosenberg, 1989). Participants respond to items like, “I feel that I have a number of good qualities;” and “I feel I do not have much to be proud of” (reverse coded) on a scale with 1= strongly disagree, 2=disagree, 3=agree, and 4=strongly agree ( = .56). Depressive symptoms were assessed using the ten item Center for Epidemiological Studies-Depression (CES-D) scale. The CES-D is a widely used measure of clinical depression and has been well-validated (Radloff, 1977). Participants report how they have been feeling in the past week in example items like, “During the past week, I felt everything was an effort;” and “During the past week, I could not get going.” Response choices range from 0=rarely or none of the time to 3=most or all of the time ( = .77). Perceived social support was measured with seven items from the Perceived Social Support Scale (Pearlin, Mullan, Semple, & Skaff, 1990). Items include, “The people close to you let you know they care about you;” and “You have a friend or relative whose opinions you value.” Response choices are 1= strongly disagree, 2=disagree, 3=agree, and 4=strongly agree ( = .89).
Psychosexual characteristics
We assessed sexual compulsivity, sexual sensation seeking, stereotypes about male sexuality, misogyny, and social-sexual effectiveness. The Sexual Compulsivity Scale consists of 10 items that “reflect obsessive preoccupations with sexual acts and encounters” (Kalichman & Rompa, 1995). An example item is, “My sexual appetite has gotten in the way of my relationships” ( = .87). The 11-item sexual sensation seeking scale is a revision of the Zuckerman sensation-seeking scale (Zuckerman & Link, 1968) and captures adventure and experience seeking in relation to sexual behavior (Kalichman et al., 1994). An example item is “I like wild and uninhibited sexual encounters” ( = .75). Both scales are measured on a 4-point scale with 1 = not at all and 4= very much like me. We used the Stereotypes About Male Sexuality Scale to measure attitudes toward male sexuality (Snell, Hawkins, & Belk, 1988). This scale captures stereotypic beliefs about males and their sexuality. Example items include, “Most men are ready for sex at any time;” and “Men are not sexually satisfied with any behavior other than intercourse” ( = .87). Misogyny is defined as hatred or strong prejudice against women simply because they are female. The 6-item misogyny scale was developed specifically for use in this research. Example items include, “In my opinion, women are bad news;” and “I avoid women except when it comes to sex” ( = .65). Social-sexual effectiveness is described as the ability to interact effectively with members of the opposite sex so as to attract sexual partners. This construct was assessed using the 14-item Male Social-Sexual Effectiveness Scale (Quackenbush, 1989). An example item includes, “I experience difficulty in understanding if a woman desires sexual intercourse” ( = .66). Stereotypes about male sexuality, misogyny, and social-sexual effectiveness are measured on a four-point scale with 1=strongly disagree to 4=strongly agree.
Sexual and substance use risk behavior
We assessed substance use during sex with FSWs, attitudes towards condoms, and condom use with FSWs. Participants were asked about their alcohol intoxication during sex and being high on drugs during sex with a FSW with two items that began with the stem “In the past 4 months, when you had sex with a prostitute in Tijuana…”: 1) “how often were you drunk?” and 2) “how often were you high on drugs?”. Responses were measured on a Likert-type scale with 1=never, 2 =once in a while, 3=fairly often, and 4=very often. We assessed attitudes towards condoms with an aggregate of five items, “Condoms interfere with sexual pleasure;” “Condoms make it more difficult for a man to keep an erection;” “Condoms make it more difficult for a man to ejaculate;” “Condoms feel uncomfortable because they are too tight;” and “Condoms are useless because they can break or slip off.” Responses choices are 1=strongly disagree to 4=strongly agree ( = .76). Participants used an open-response format to report the number of the following during the past four months when they had sex with a female sex worker in Tijuana: times of vaginal sex, times condom used for vaginal sex, times of anal sex, times condom used for anal sex. We computed the proportion of unprotected sex acts with a FSW in the past four months by subtracting the total number of times a condom was used during vaginal and anal sex from the total vaginal and anal sex acts, and dividing total sex acts by that difference.
Data Analyses
Data were analyzed in four stages. First, we examined descriptive statistics on perceived stigma of purchasing sex among the entire sample. Next, we examined demographic differences between Latino and non-Latino male clients. We used a t-test for age and logistic regressions for all other demographic variables. Third, we conducted linear regression analyses to examine associations between perceived stigma of purchasing sex and attitudes and beliefs about FSW and purchasing sex, psychosocial factors, psychosexual factors, substance use during sex, condom attitudes and condom use with FSW, separately between the two ethnic groups. For these analyses, we conducted separate linear regressions predicting perceived stigma for each variable. We controlled for age, living in the U.S., deportation status, marital status, having children, employment status, and religion (i.e., Catholic v. non-Catholic). Finally, we examined independent correlates of perceived stigma of purchasing sex in separate multivariate regression models for both Latino and non-Latino male clients. Variables that were significantly associated with perceived stigma at the p < .10 level in bivariate analyses were included in the multivariate analyses.
Results
Descriptive statistics
On average, participants tended to agree that purchasing sex was stigmatized (M=2.76, SD=0.50). A total of 323 (86%) participants self-reported as Hispanic/Latino, and 52 (14%) participants self-reported as non-Hispanic/Latino. A t-test showed that Latinos (M=2.80, SD=0.51) perceived greater stigma than non-Latinos (M=2.56, 0.45) (t = -3.20, p <.01; data not shown).
Demographic differences
Table 1 shows that compared to non-Latino male clients, Latino male clients were less likely to live in the United States, and were more likely to have been deported from the U.S., be married, have children, be employed, and be Catholic.
Table 1. Demographic differences between Latino and Non-Latino male clients of FSWs in Tijuana, Mexico (n=375).
| Latino (n=323) | Non-Latino (n=52) | ||||
|---|---|---|---|---|---|
|
|
|||||
| n | % | N | % | OR (95% CI) | |
| Live in U.S. | 138 | 42.7% | 46 | 88.5% | 0.10 (.040, .234)*** |
| Deported from the U.S. | 129 | 39.9% | 2 | 3.8% | 16.62 (3.98, 69.52)*** |
| Married/Common Law | 113 | 35.0% | 3 | 5.8% | 8.79(2.68, 28.83)*** |
| Any children | 226 | 70.0% | 28 | 53.8% | 2.00(1.10, 3.62)* |
| Employed | 203 | 62.8% | 26 | 50.0% | 1.69(.94, 3.05)† |
| Catholic | 199 | 61.6% | 19 | 36.5% | 2.79(1.52, 5.12)*** |
| Gay/Bisexual | 42 | 13.0% | 7 | 13.5% | 0.96(.41, 2.28) |
| M | SD | M | SD | T | |
|
|
|||||
| Age | 37.19 | 10.11 | 42.46 | 12.48 | 2.90** |
Notes:
p<.10,
p<.05,
p<.01,
p<.001
Correlates of perceived stigma among Latino and non-Latino clients
We examined the correlates of perceived stigma of purchasing sex among both ethnic groups, over and above demographic differences. Table 2 summarizes results. Attitudes and Beliefs about Seeing FSWs: Among Latino male clients, perceived stigma of purchasing sex was associated with more general guilt about seeing FSWs. For example Latino clients who reported feeling “bothered about having a secret life of going to prostitutes” (β = 0.22, t =4.00, p <.001) reported greater perceived stigma of purchasing sex. Both Latino and non-Latino clients who reported greater perceive stigma also reported “feeling badly about spending money on prostitutes” (β = 0.24, t =4.43, p <.001). However, the two groups exhibited opposite patterns for two items regarding attitudes about seeing FSWs. First, for Latino clients greater perceived stigma was associated with greater agreement that the thought of “getting caught with a prostitute” made them aroused (β = 0.18, t =3.22, p <.001), whereas for non-Latino clients greater perceived stigma was associated with greater disagreement with this statement (β = -0.40, t =-2.58, p <.01). Second, Latino clients who reported greater stigma also reported a greater preference of having sex with FSWs in a setting where there is risk of getting arrested (β = 0.13, t =2.38, p <.05), whereas non-Latino clients reported the opposite (β = -0.36, t = -2.59, p <.01). Psychosocial characteristics: Latino clients with higher depressive symptoms (β = 0.18, t = 3.21, p <.001) and more perceived social support (β = 0.14, t = 2.47, p <.01) also reporter higher perceived stigma of purchasing sex. These clients also tended to report lower self-esteem (β = -0.10, t = -1.81, p <.10). Perceived stigma was not associated with any of the psychosocial characteristics among non-Latino male clients. Psychosexual Characteristics: Latino clients who reported higher perceived stigma reported higher sexual compulsivity (β = 0.12, t = 2.13, p <.01) and endorsed more traditional stereotypes about male sexuality (β = 0.32, t = 5.81, p <.05). Non-Latino clients with greater perceived stigma reported lower misogyny (β = −0.33, t = −2.14, p <.05). Stigma was not associated with sexual sensation seeking or social-sexual effectiveness among either group. Sexual and drug risk behavior: Latino clients who reported greater perceived stigma of purchasing sex also reported a lower frequency of being high on drugs during sex with FSWs (β = −0.17, t = −3.01, p <.001), more negative attitudes towards condoms (β = 0.33, t = 6.23, p <.001), and a marginally greater proportion of unprotected sex with FSWs (β = 0.10, t = 1.78, p <.10). Stigma was not associated with drug and sexual risk behavior among non-Latino clients.
Table 2. Linear regressions examining correlates of perceived stigma of purchasing sex by ethnicity among male clients of FSWs in Tijuana, Mexico (n=375)a.
| Latino (n=323) | Non-Latino (n=52) | |||
|---|---|---|---|---|
|
|
|
|||
| β | t | β | t | |
| Attitudes and Beliefs about Seeing FSWs | ||||
| I feel badly about spending money on prostitutes. | 0.24 | 4.43*** | 0.34 | 2.19* |
| Having sex with a prostitute conflicts with my religious beliefs. | 0.26 | 4.73*** | 0.20 | 1.41 |
| I feel guilty about having sex with prostitutes. | 0.26 | 4.79*** | 0.22 | 1.47 |
| I feel guilty if I have unprotected sex with a prostitute. | 0.21 | 3.78*** | 0.13 | 0.87 |
| I feel badly for my (wife/steady partner) when I have sex with a prostitute. | 0.10 | 1.77† | 0.31 | 2.02* |
| I worry that my (wife/steady partner) will find out about my going to prostitutes. | 0.14 | 2.40* | 0.15 | 0.96 |
| It bothers me that I have a secret life of going to prostitutes. | 0.22 | 4.00*** | 0.07 | 0.43 |
| I get turned on when I think about getting caught with a prostitute. | 0.18 | 3.22*** | −0.40 | −2.58** |
| I get a thrill out of doing something “bad” like going to a prostitute. | 0.17 | 3.04*** | −0.08 | −0.52 |
| Going to a prostitute allows me to escape my everyday life. | 0.33 | 6.13*** | 0.18 | 1.22 |
| Going to a prostitute helps to fulfill my sexual fantasies. | 0.26 | 4.77*** | 0.19 | 1.23 |
| I like the danger associated with going to a prostitute. | 0.16 | 2.90*** | −0.02 | −0.12 |
| I prefer to have sex with prostitutes in a setting where there is a risk of getting arrested. | 0.13 | 2.38* | −0.36 | −2.59** |
| Psychosocial Characteristics | ||||
| Self-esteem | −0.10 | −1.81† | −0.10 | −0.61 |
| Depression | 0.18 | 3.21*** | 0.02 | 0.15 |
| Social support | 0.14 | 2.47** | 0.05 | 0.31 |
| Psychosexual Characteristics | ||||
| Sexual compulsivity | 0.12 | 2.13* | −0.02 | −0.15 |
| Sexual sensation seeking | 0.06 | 1.03 | 0.21 | 1.40 |
| Stereotypes about male sexuality | 0.32 | 5.81*** | 0.22 | 1.48 |
| Misogyny | 0.06 | 1.06 | −0.33 | −2.14* |
| Social-sexual effectiveness | 0.05 | 0.95 | 0.14 | 0.91 |
| Substance Use During sex with FSWs | ||||
| High on drugs during sex with FSWs past 4 mo. | −0.17 | −3.01*** | −0.14 | −0.90 |
| Drunk on alcohol during sex with FSWs past 4 mo. | −0.01 | −0.17 | −0.01 | −0.04 |
| Attitudes towards Condoms and Condom Use | ||||
| Negative attitudes towards condoms | 0.33 | 6.23*** | 0.01 | 0.05 |
| Prop. of unprotected sex acts with FSWs past 4 mo. | 0.10 | 1.78† | 0.02 | 0.10 |
Notes:
p<.10,
p<.05,
p<.01,
p<.001;
Controlling for age, living in the U.S., deportation status, marital status, having children, employment status, and religion (i.e., Catholic v. non-Catholic)
Multivariate Models
Tables 3 and 4 summarize the results for separate multivariate models for Latino and non-Latino male clients, respectively. Factors uniquely associated with perceived stigma of purchasing sex among Latino clients were younger age, not being married/common law union, feeling badly about spending money on FSWs, feeling like FSWs allow an escape from everyday life, greater social support, a lower likelihood of being high on drugs during sex with a FSW, and more negative attitudes about condoms. Among non-Latino clients, perceived stigma was uniquely associated with a lower likelihood of feeling aroused at the thought of getting caught with an FSW.
Table 3.
Multivariate linear regression model predicting perceived stigma of purchasing sex among Latino male clients of FSWs in Tijuana, Mexico (n=323).
| β | t | |
|---|---|---|
| Demographics | ||
| Age | −0.14 | −2.43* |
| Live in U.S. | 0.07 | 1.15 |
| Deported | 0.07 | 1.25 |
| Married/Common Law | −0.11 | −1.98* |
| Any Children | 0.01 | 0.15 |
| Employed | 0.03 | 0.65 |
| Catholic | 0.04 | 0.84 |
| Attitudes and Beliefs about Seeing FSWs | ||
| I feel badly about spending money on prostitutes. | 0.13 | 2.08* |
| Having sex with a prostitute conflicts with my religious beliefs. | 0.07 | 1.09 |
| I feel guilty about having sex with prostitutes. | 0.03 | 0.43 |
| I feel guilty if I have unprotected sex with a prostitute. | 0.08 | 1.18 |
| I feel badly for my (wife/steady partner) when I have sex with a prostitute. | −0.02 | −0.29 |
| I worry that my (wife/steady partner) will find out about my going to prostitutes. | −0.04 | −0.48 |
| It bothers me that I have a secret life of going to prostitutes. | 0.05 | 0.86 |
| I get turned on when I think about getting caught with a prostitute. | 0.01 | 0.18 |
| I get a thrill out of doing something “bad” like going to a prostitute. | −0.08 | −1.16 |
| Going to a prostitute allows me to escape my everyday life. | 0.17 | 2.78** |
| Going to a prostitute helps to fulfill my sexual fantasies. | 0.07 | 1.01 |
| I like the danger associated with going to a prostitute. | −0.02 | −0.29 |
| I prefer to have sex with prostitutes in a setting where there is a risk of getting arrested. | 0.06 | 1.13 |
| Psychosocial Characteristics | ||
| Self-Esteem | −0.10 | −1.72† |
| Depression | 0.06 | 0.97 |
| Social Support | 0.12 | 2.06* |
| Psychosexual Characteristics | ||
| Sexual Compulsivity | 0.03 | 0.50 |
| Stereotypes about male sexuality | 0.07 | 0.98 |
| Substance Use During sex with FSWs | ||
| High on drugs during sex with FSWs past 4 mo. | −0.15 | −2.74** |
| Drunk on alcohol during sex with FSWs past 4 mo. | −0.05 | −0.91 |
| Attitudes towards Condoms and Condom Use | ||
| Negative attitudes towards condoms | 0.12 | 1.94* |
| Prop. of unprotected sex acts with FSWs past 4 mo. | 0.09 | 1.59 |
Notes:
p<.10,
p<.05,
p<.01,
p<.001
Table 4.
Multivariate linear regression model predicting perceived stigma of purchasing sex among Non-Latino male clients of FSWs in Tijuana, Mexico (n=52).
| β | t | |
|---|---|---|
| Demographics | ||
| Age | −0.12 | −0.84 |
| Live in U.S. | −0.13 | −0.79 |
| Deported | 0.25 | 1.45 |
| Married/Common Law | −0.36 | −1.61 |
| Any Children | −0.09 | −0.63 |
| Employed | 0.22 | 1.52 |
| Catholic | 0.06 | 0.42 |
| Attitudes and Beliefs about Seeing FSWs | ||
| I feel badly about spending money on prostitutes. | 0.20 | 1.31 |
| I feel badly for my (wife/steady partner) when I have sex with a prostitute. | 0.21 | 1.39 |
| I get turned on when I think about getting caught with a prostitute. | −0.37 | −2.50* |
| I prefer to have sex with prostitutes in a setting where there is a risk of getting arrested. | −0.15 | −1.03 |
| Psychosexual Characteristics | ||
| Misogyny | −0.18 | −1.22 |
Notes:
p<.10,
p<.05,
p<.01,
p<.001
Discussion
Understanding the different concerns and issues involved in sex work is paramount to developing comprehensive and efficacious HIV risk reduction interventions. Whereas male clients of FSWs may be considered as engaging in deviant behavior (Prieur & Taksdal, 1993), research has not studied perceived stigma of purchasing sex among this population. Further, cultural considerations must be taken when studying stigma of purchasing sex, as societal and cultural norms may often dictate sexual behavior. In this study, we examined stigma of purchasing sex among Latino and non-Latino male clients of FSWs in Tijuana, Mexico. In general, the results showed that over and above demographic factors like age, marital status, and Catholicism, among Latinos perceived stigma is associated with more guilt about purchasing sex, a feeling that FSWs allow for an escape from everyday life, higher social support, and more negative attitudes towards condoms. These patterns were not found among non-Latino clients, who instead reported a lower likelihood of reporting arousal at the thought of getting caught with a FSW the more stigma they perceived. The fact that we controlled for demographics like living in the U.S. and Catholicism suggests that ethnic and cultural factors may account for the pattern of results found here.
Part of machismo means that Latino men, compared to non-Latino men, may feel more social obligations to the family. In this study Latino clients who reported greater perceived stigma, or who were more likely to believe that they would be looked down upon in society because of purchasing sex, reported greater social support, more guilt, and a greater feeling of escape that sex workers bring them. Thus, it may be that Latino male clients who report greater perceived stigma of seeing sex workers may also have more close others that may potentially be shamed or disappointed by their behaviors. In addition, although they may feel more guilt about seeing and having sex with FSWs, this act may allow them an escape from their responsibilities and pressures of everyday life. Latino clients who report greater perceived stigma also reported more negative attitudes about condoms. Previous work has found that in general, Latinos have poorer attitudes toward condoms than non-Latino Whites (Espinosa-Hernández & Lefkowitz, 2009; Marín et al., 1993). It may be a general conservative orientation or value system that may account for both higher perceived stigma and poorer condom attitudes, which was not measured here. Future research using longitudinal methods may better elucidate the nature of these relationships.
The meaning of perceived stigma of purchasing sex appears to be different for non-Latino male clients of FSWs. Non-Latino men were less likely to agree that the thought of getting caught with a FSW arouses them. This may partly be a function of the fact that sex work is tolerated in Mexico, whereas it is criminalized in the U.S. Although this finding held after controlling for living in the U.S., it is possible that non-Latino men feel less social and familial pressures, and that having sex with FSWs has less to do with escaping from everyday life, and more to do with the sex in and of itself.
The results of the current study should be interpreted cautiously in light of its limitations. The data were gathered cross-sectionally, prohibiting conclusions about the directionality of the relationships. Although ideal for the aims of the current paper, our sample consisted of male clients of FSWs in Tijuana, Mexico. Therefore, we cannot infer that our findings are generalizable to other male clients of FSWs around the globe. And, in fact, the environment of Tijuana, where sex work is quasi-legal and clients come from both inside and outside of Mexico, make this setting somewhat unique. Nonetheless, the dynamic and growing HIV epidemic among FSWs in Tijuana is cause for concern and tailored interventions are needed for this population. As a function of our design, our non-Latino sample was relatively small compared to our Latino sample, potentially yielding low statistical power. However, the fact that we did find statistically significant results among this subgroup suggests that this is less likely. We also found low reliability for the self-esteem scale; future work should examine its psychometric properties in this border population. Altogether, the current results have important implications for culturally tailored HIV prevention interventions.
There is a general consensus in the literature that HIV-related stigma is important to address in HIV prevention efforts, as it can affect testing behaviors, as well as disclosure processes and sexual risk behaviors, among other things (Earnshaw & Chaudoir, 2009; Hatzenbuehler, O'Cleirigh, Mayer, Mimiaga, & Safren, 2011; Pitpitan et al., 2012). However, people often live with multiple, intersecting stigmatized identities (Earnshaw & Kalichman, 2013), . That is, people might experience stigma due to their HIV-positive status, as well as because they purchase sex from FSWs. These multiple identities should be considered in risk reduction programs. Perceived stigma can be part of the experience of being a client involved with sex work, and it may directly or indirectly lead to risk behavior and HIV transmission (e.g., via negative attitudes towards condoms). HIV prevention efforts that target male clients must address perceived stigma of purchasing sex, and as this study has shown, how it is addressed may depend on the cultural background of the client. Counseling with Latino male clients regarding perceived stigma should center on discussions about cultural or familial issues, for example discussing machismo and family obligations. Future research should examine perceived stigma among male clients of FSWs in other regions and among other ethnic groups to better shed light on cultural factors that may moderate or underlie the relationship between stigma of purchasing sex and HIV risk.
Acknowledgments
Preparation of this manuscript was supported by a National Institute on Drug Abuse training fellowship for Eileen V. Pitpitan (T32DA023356), Karla D. Wagner (K01DA031031) and a National Institute of Mental Health training fellowship for Valerie A. Earnshaw (T32MH02003). This project was funded by a National Institute on Drug Abuse grant R01DA029008.
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