Sex Work, Heroin Injection, and HIV Risk in Tijuana: A Love Story

Abstract

The relationships between female sex workers and their non-commercial male partners are typically viewed as sites of HIV risk rather than meaningful unions. This ethnographic case study presents a nuanced portrayal of the relationship between Cindy and Beto, a female sex worker who injects drugs and her intimate, non-commercial partner who live in Tijuana, Mexico. Based on ethnographic research in Tijuana and our long term involvement in a public health study, we suggest that emotions play a central role in sex workers’ relationships and contribute in complex ways to each partner’s health. We conceptualize Cindy and Beto’s relationship as a “dangerous safe haven” in which HIV risk behaviors such as unprotected sex and syringe sharing convey notions of love and trust and help sustain emotional unity amidst broader uncertainties, but nevertheless carry very real health risks. Further attention to how emotions shape vulnerable couples’ health remains a task for anthropology.

INTRODUCTION

When my colleague and I arrived mid-morning, Cindy and Beto had already been waiting to “connect” (purchase drugs) for several hours. They woke up “really sick” and she sold her cell phone to raise money for their “cure,” or enough heroin to make them feel better. Cindy appeared anxious and preoccupied, sniffled frequently, and even though the dry heat of the day had not yet kicked in, she was sweating profusely from a “malilla” of drug withdrawal symptoms that sends addicted bodies into chills, sweats, stomach cramps, diarrhea, aches and pains, and intense anxiety. She brought a couple of chairs outside so we could sit comfortably in the shade of their front yard while she anxiously joined Beto on the street corner to connect.

To “connect” in their Tijuana, Mexico, neighborhood, they must flag down dealers driving along designated routes throughout the day. The corner in front of Beto’s family property is a popular stop where as many as 15–20 local injectors start to congregate as early as 7 a.m. to connect. Black tar heroin and crystal methamphetamine are wrapped in small plastic packages and encased in colored balloons to indicate drug type – blue and red balloons are 50 pesos of heroin, while yellow, pink, green, and sometimes black are 50 pesos of crystal. For their morning cure, they need 100 pesos of heroin (equivalent to about ~ $8 U.S.). Although we didn’t see the purchase from our vantage point, we noted their success when they hurried back inside their fenced property and disappear into their single room structure. After a minute or so, Cindy poked her head outside the blue and white striped curtain that covered the doorway and asked if it would be “helpful” to watch them inject.

We humbly entered their home that Beto built himself. It is modest with simple functional furniture. Beto had scrawled a series of love messages dedicated to Cindy in marker on one of the walls including, “te amo y te amare por siempre mi flackis” (I love you and I’ll always love you, my skinny lady), “tu lugar está aquí en mi corazón” (your place is here in my heart), and “tú y yo por siempre” (you and me forever).

As we settled in, Beto was already stirring the heroin and water in a cooker (bottom of a soda can) using the butt of a syringe plunger. We hadn’t seen him heat the drug, but the lighter on the table is evidence that the sticky consistency of black tar heroin needs to be heated to liquefy it into an injectable form. As he stirred the murky mixture in the cooker, she reached into her dresser and explained that for a filter, “you can get the cotton from anywhere, socks, underwear, a shirt, cigarette, whatever.” She then grabbed syringes for each of them, which were stored out in the open, on top of their desk. Beto prepared the injections on the floor in the light of the single window; without electricity and even in the daytime, it can be difficult to see. Beto used sock fluff as a filter and drew up the entire heroin mixture into his syringe before removing the plunger from her syringe and “backloading” half of the liquid into it. On the floor near the cooker, I noted that the heroin balloons were blue that day.

After they each had their loaded syringes in hand, they started the injection process. We all grew quiet to concentrate, they on injecting, and we on observing them injecting. The drug mixture appeared black and thick inside their syringes. They each tried multiple sites of injection on their bodies in a struggle to find relief from their malilla. Several times throughout the arduous process, which lasted about 45 minutes, they held their syringe up to the light of the window, flicked it with a thumb and middle finger to knock the air out, and licked the needle as part of an injection ritual that also attempted to avoid wasting any precious drops.

Cindy sat down on the floor and looked intently for veins in her right foot. She said she had luck there the day before, but after several futile attempts, she announced, “there aren’t any today.” She previously told me that successful injection episodes for her can take up to several hours. Beto estimated that she has taken up to five hours to inject. But this morning, she was sick and resorted to injecting herself in the muscle in her upper left arm. She slowly and precisely inserted and withdrew the needle from her flesh. She explained that while the rush is not as intense, it nonetheless provides immediate relief from her symptoms of malilla. Her mood immediately lightened and she commented that her nose stopped running “without even blowing it!”

Meanwhile, Beto tied a tourniquet (a strip of a material) on his arm and attempted injection inside his upper left arm. She relayed that she too used to inject in her armpit and underneath her arm, but that she can no longer find veins there. As he struggled and wiggled the needle inside his flesh, she gasped “¡cuidate!” (be careful) but he said it was too late … he had already injected a few drops but missed the vein, resulting in a burning sensation in his flesh. He tried again and missed, but this time the burning was worse. He pulled the needle out, but his arm was already starting to swell and he appeared to be developing bright red hives. His arm, face, and chest turned red and glistened with sweat. He appeared to be in pain. His hand swelled to nearly twice its size. He held his hand out to us and instructed us to feel it—it was rock hard to the touch and he could barely grasp his fingers into a fist. He said this “mano de Popeye” (Popeye hand) happens frequently when he hits a “nerve” and that it takes several hours for the symptoms to subside.

Attentive to his discomfort, Cindy then tried to help him inject. They propped a mirror up in the light of the windowsill and she first tried to inject him into his left collarbone area. She tried a few times and he grimaced during the process. She apologized for hurting him. She sat down on the floor, and almost by chance observed a potential opportunity in his leg. She instructed him to stand still as she examined his right calf and quickly affirmed her luck. She tied the tourniquet at his knee, loudly slapped his right calf to fully engorge the vein, and patiently injected the rest of the contents of his syringe into the vein in the back of his calf. She injected him relatively easily, at least compared to their other injection attempts. Once they were finished, she stood up, and they embraced and kissed. The process was complete. They were cured.

- Edited fieldnotes, 08/17/2011

This ethnographic case study explores the emotional dimensions of HIV risk between Cindy and Beto, a female sex worker who injects drugs and her intimate, noncommercial partner who live in Tijuana, Mexico. Based on ethnographic research in Tijuana and our long term involvement in a public health study, we suggest that emotions play a central but complex role in shaping sex workers’ relationships and each partner’s health and wellbeing. Specifically, this narrative portrays Cindy and Beto’s relationship as a “dangerous safe haven”¹ in which love and intimacy are embodied in sexual behaviors and heroin injection practices that offer emotional refuge from the broader HIV risk environment that united them as a couple.

Although Tijuana is a cosmopolitan city of more than 1.6 million inhabitants that boasts vibrant cultural, culinary, and arts scenes, its reputation for sexual tourism, drug use, and gruesome cartel violence often overshadows its virtues in popular imagination. Sex work is technically regulated in Tijuana. However, much of it occurs under the radar of the municipal registration system, particularly among street-based sex workers who use drugs and are at highest risk for infectious diseases (Sirotin, et al. 2010). Drug abuse, including injection drug use, has increased in Tijuana in recent years (Instituto Nacional de Salud Publica 2008) in part due to its location on a major U.S.-bound drug trafficking route. Mexican black tar heroin and crystal methamphetamine dominate the local drug trade (Bucardo, et al. 2005). Although personal drug possession has been nationally decriminalized and harm reduction services are available in Tijuana, repressive policing practices and discrimination frequently impinge on injectors’ abilities to adopt safer behaviors (Pollini, et al. 2011; Volkmann, et al. 2011).

Importantly, drug addiction must be understood within the broader HIV risk environment of Tijuana, including the everyday violence of limited economic opportunities, discrimination, and stigma that characterize the experiences of many socially marginalized individuals on the border (Beletsky, et al. 2012; Brouwer, et al. 2009). Merrill Singer (2001:204) conceptualizes these factors as the “oppressive forces [that] create the social, emotional, and physical conditions that invite and sustain drug dependency” (Singer 2001) (emphasis added). While researchers have frequently characterized the social and physical conditions of drug addiction, recent scholarship has turned to the emotional dimensions of this illness. Angela Garcia (2010) explored intergenerational addiction as an expression of longing for connection to familial emotional and geographic territories (Garcia 2010). Phillipe Bourgois and Jeff Schonberg’s (2009) research followed the close relationships of a network of homeless heroin addicts, including the “outlaw love” of Tina and Carter, to trace how historical structural factors shape the subjectivities of the most marginalized in society (Bourgois and Schonberg 2009). Building on this attention to the intimate aspects of addiction, our work examines one couple’s emotional experiences of sex work, heroin injection, and HIV risk as they are shaped by the liminality of failing U.S. drug policies to the north and inadequate social safeguards on the southern Mexican side of the border.

Our analysis is guided by a critical phenomenology approach (Desjarlais 1997), which combines concern over lived experience with political economy perspectives that highlight the historical and structural production of risk. Central to this framework is the vulnerability of the “mindful body” whereby life experiences become inscribed on the body and emotions provide a critical “missing link” bridging subjective and structural dimensions of experience (Scheper-Hughes and Lock 1987). Our approach examines HIV risk behaviors through the lens of love, which connotes intimacy, commitment, trust, and emotional connection between partners. As a holistic construct, love is a useful medium through which to link emotional, social, and structural dimensions of personal experience (Padilla, et al. 2007). Structural conditions bring partners together into emotionally intimate relationships and shape their private risk behaviors as ways to hold onto each other amidst uncertainty (Rhodes and Cusick 2002; Sobo 1995). Our work argues that love and risk are mutually constituted dimensions of sex workers’ intimate relationships: this paradox is the fabric from which “dangerous safe havens” are woven.

The story of Cindy and Beto illustrates how love and other emotions are enacted and embodied within broader structures of HIV risk. Our study was nested within Proyecto Parejas (the Couples Project), a social epidemiology study of HIV/STI risk among female sex workers and their intimate, non-commercial partners in Tijuana and Ciudad Juarez, Mexico, as detailed elsewhere (Syvertsen, et al. 2012). Here, we present original data collected in 2011 as part of our ethnographic sub-study of the role of emotions in shaping sexual and drug-related HIV risk within sex workers’ intimate relationships.

CINDY & BETO

The lead author first met Cindy, age 29, in the Zona Norte project office in 2010. In administering her epidemiologic survey as part the Parejas study, she asked, “On a scale of one to ten, how much do you trust your partner?” Cindy responded: “Thirteen.” The sincerity in her answer and the inability of the quantitative survey to capture her sentiment helped plant the seeds for this sub-study. One year later, Cindy and her partner Beto were the first couple to enroll.

Although the authors had interacted with each participant in the project offices, it was not until they engaged in individual life history interviews that the extent of hardship and emotional turmoil that Cindy and Beto have experienced became apparent. Cindy has long, impossibly thick black hair and curves that she often showcased in tight jeans. She was frank, outgoing, funny, and often emotionally charged in her interviews: she sobbed when recounting deeply hurtful events from childhood and alternately laughed heartily when telling stories about Beto, like the time he stole someone’s bike who was too high to notice and sold it for 100 pesos and several tamales. Cindy was smuggled by coyotes to San Diego as a child and spent her formative years under her grandmother’s care. Never naturalized as a citizen or encouraged in school because she would just “get married and have babies” anyway, Cindy felt she never reached her potential. Her grandmother’s boyfriend sexually abused her for years, ultimately prompting her to leave home and high school. Her strained relationship with her mother, who was mostly absent from her life, and the influence of an ex-boyfriend pushed her to first try drugs. She was heavily involved in drugs and selling large quantities of heroin when she was deported from the United States for robbing an ice cream shop at gunpoint.

Estranged from her family, she relied on help from another deportee after arriving in Tijuana. She was introduced to a man with whom she could stay in exchange for cleaning his house. Soon after, she moved in with a boyfriend who sold methamphetamine. He was often violent, including the day he killed her kitten Gemini in a fit of rage. Cindy left him and narrowly escaped death when he angered his drug suppliers, who locked him, his brother, and his brother’s girlfriend and baby inside their house, set it on fire, and burned them all alive. Shortly afterwards, she met Beto while they were both waiting to “connect” one day.

Born and raised in Tijuana, Beto, age 33, completed school through the third grade. He used drugs and went to prison at a young age, and eventually got married but never felt connected to his non-drug using wife with whom he had two children. During his marriage, he navigated a period of sobriety and held a regular job, but he was not content. At one point, he lived on the streets with a small group of drug users who engaged in elaborate schemes to steal merchandise and evade the police to survive. He was caught, however, and after serving time in prison, he was released only to find that his companions had all died from AIDS and other drug-related causes.

Beto hardly fits the stereotypical image of a long-time drug user with a prison record. He has a slight build, friendly brown eyes, and a shaved head often hidden under a baseball hat. Sometimes his skin is scabbed from smoking methamphetamine and picking at it, as users often do to quell the crawling sensation under their skin. He steals bikes, stereos, wiring in houses, and other opportune goods as well as works odd mechanic jobs to hustle for drugs and support his life with Cindy.

Beto was soft spoken in his individual interviews and he became deeply emotional when describing the importance of his relationship with Cindy over the past two years. He recounted a period of heavy methamphetamine use when he incessantly picked at his skin all over his body to the point that his clothes uncomfortably stuck to him and he felt ashamed. Beto said Cindy remained with him, did not judge, and instead offered her support. He became deeply reflective as he described his feelings for Cindy, which also revealed his own emotional comportment: “But then you find the person with whom you can really share who you are, what you feel, and you look at another person just like you, who is docile, who is kind, loving, sensitive, the smallest thing can hurt them and they can cry like a child.”

Cindy described Beto as “different than any other partner I’ve had.” Beto affectionately calls her his sirenita (little mermaid) and the love messages on their wall at home offers material evidence of his affection for her. They interacted closely and showed each other small displays of affection, even when they didn’t know the lead author was observing them hold hands and eat ice cream in the street below the project office windows one day. Cindy said that she could not see her life without him, and Beto said “she is everything” to him.

As the ultimate sign of love in Cindy’s eyes, Beto accepted her dog Lucia into their family despite never caring for dogs. Cindy always wanted children but could not get pregnant; her intense attachment to her dog partially fills that void. Early in their relationship, Cindy asked Beto if Lucia could live with them and she was prepared to leave if he said no. Their first night together, to Beto’s horror, Lucia slept in the bed with them. Yet he tolerated it for Cindy and has gradually come to accept the dog and her subsequent litters of puppies, one of which he has grown particularly attached to. Cindy said that Lucia has had the same father for all three litters of puppies, and this dog always comes back to check on her after she gives birth. She said that just like she and Beto, the dogs are in love.

DANGEROUS SAFE HAVENS

Recent anthropological scholarship has highlighted the importance of love and emotional intimacy in forging intimate relationships in diverse global contexts (Hirsch and Wardlow 2006; Padilla, et al. 2007). For vulnerable couples like Cindy and Beto who live in a risk environment marked by material deprivation, violence, high disease prevalence, and social and political marginalization (Rhodes 2009), establishing and maintaining bonds with intimate partners is of paramount importance for securing emotional and material wellbeing (Sobo 1995). We further suggest that these relationships transform into “dangerous safe havens” in which HIV risk behaviors such as unprotected sex and syringe sharing convey notions of love and trust and help sustain emotional unity but nevertheless carry very real health risks.

Like other female sex workers who demarcate condom use and reserve certain sexual activities for their intimate, non-commercial partners (Allen, et al. 2003; Jackson, et al. 2009; Warr and Pyett 1999), Cindy distinguishes work from her relationship with Beto. Cindy described sex work as “putting my mind out of my body, like you’re borrowing a body.” In contrast, she embodies her unprotected sexual experiences with Beto as a pleasurable pursuit from which she derives personal meaning. She reserves the “sacred” act of kissing only for him. In this way, she never openly violates the emotional intimacy of her relationship with Beto.

While the emotional meanings ascribed to sexual behaviors have been well described (cf. Corbett et al. 2009; Sobo 1995), less attention has been given to the emotional dimensions of couples’ drug use. While drug use complicates intimate relationships by introducing physical, social, and legal risks, concern over drug-related harm is often secondary to maintaining relationships (Rhodes and Quirk 1998; Simmons and Singer 2006). Research also consistently shows that syringe sharing is common among couples (Barnard 1993; Bryant, et al. 2010; Go, et al. 2006). However, many health studies portray female injectors’ behaviors as largely controlled by their male “sex partners” without providing sufficient attention to the emotional meanings of such relationships. Male perspectives on drug use are often presented as individual risk behaviors divorced from their intimate social relationships and devoid of meaning.

Instead, we suggest that injection drug practices are embroidered in the formation of dangerous safe havens. The excerpt from fieldnotes that opens our article not only offers a rare glimpse of the intimate side of heroin addiction, but illustrates the emotional component of addiction among intimate couples. We later asked Cindy if the events described above constituted a “typical” injection episode. She said that for the most part, it was. Although she did not usually inject Beto, that day he was having difficulties and she wanted to help. Injecting can be a difficult and painful process, and having a caring partner can be beneficial.

Cindy and Beto’s years of injecting black tar heroin have damaged their veins and shape their injection practices. The properties of black tar heroin may accelerate venous inflammation and create track marks (scars that appear along the veins from repeated injection in the same sites), which forces them to inject in dangerous parts of their bodies and sometimes requires assistance from others (Ciccarone 2009). Lengthy injection episodes also allow time for the needle to clog. In addition to indirect sharing (e.g. drug mixture, cooker, cotton), Cindy and Beto often borrow each other’s syringes when their own becomes too dull from repeated use or gets clogged. This type of receptive syringe sharing represents a highly efficient form of transmitting blood-borne infections. However, from their standpoint, sharing makes sense. The ideal of a new, sharp, clean syringe for each injection can be unrealistic within the constraints of syringe cost, availability, and embodied fear of punitive policing practices surrounding syringe possession (Pollini, et al. 2008). Besides, as Cindy reasons, they do not use condoms either so “it doesn’t matter.”

Cindy often has extreme difficulty injecting, which is why she sometimes injects into her muscle, as we had witnessed and as evidenced by the bruises all over her body. Beto also frequently struggles to inject, and as described in the fieldnotes, he sometimes misses his veins and suffers from a bloated extremity like a cartoon character after eating spinach (Popeye hand). This reaction is most likely due to injecting into an artery (rather than a “nerve”), causing a potentially dangerous inflammatory response.

Cindy and Beto have embodied the impurities of the Tijuana drug market and the “War on Drugs” writ large in the form of infections, track marks, wounds, and adverse reactions at injection sites all over their bodies. These injuries not only threaten their physical health but also mark them socially as drug users. A recent epidemiologic analysis found that being arrested for track marks was independently associated with HIV infection in a cohort study of injection drug users in Tijuana. The authors argued that arrest for track marks represented the stigma and discrimination that reinforced drug users’ social marginalization, ultimately perpetuating their risk (Strathdee, et al. 2008).

Ethnographically, our work humanizes these statistical studies. Within the framework of critical phenomenology, we invoke the concept of structural vulnerability to understand the emotional lived experience of addiction among couples. Like other injectors in Tijuana, Cindy and Beto face extraordinary structural vulnerabilities vis-a-vis their disadvantaged position both literally and figuratively on the border of society. This positioning imposes patterned physical and emotional suffering among marginalized groups that becomes internalized into their subjective experience (Quesada, et al. 2011). These structural conditions bring partners together to form dangerous safe havens in which HIV risk behaviors are embodied acts of emotional intimacy that both protect and endanger partners while sustaining the relationship. Long before they met, Cindy and Beto’s difficult childhoods and repeated traumatic experiences helped create the circumstances in which they blamed themselves for their plight and self-medicated with drugs to numb their pain. Limited opportunities, violence, sexual abuse, incarceration, deportation, and the other ongoing hardships that mark their lives have profoundly shaped their emotional lived experiences. Beto, in fact, refers to addiction as an “emotional disease” that begins at a young age.

For Cindy and Beto, neither are as concerned about acquiring HIV as much as trying to protect each other from a lifetime of physical and emotional malilla (Connors 1994). The dangerous safe haven that they have constructed may perpetuate their addiction and heighten their vulnerability to infection, but it also gives their lives meaning and enables their survival despite hardships and uncertainty. It is this paradoxical co-occurrence of love and risk that defines the very essence of their relationship.

FINAL THOUGHTS ON LOVE AND RISK

Invariably, this analysis of Cindy and Beto’s relationship is fraught by the limitations inherent in anthropological scholarship. First, this case study is not representative of all sex worker couples. Among all couples enrolled in Parejas, we found that just like intimate relationships in other contexts, sex workers’ relationships varied in emotional quality and intensity (Syvertsen, et al. 2013). Our case study of Cindy and Beto highlights the co-occurrence of love and risk among emotionally close couples who endure difficult life circumstances, representing one but certainly not the only relationship configuration between two vulnerable individuals.

We also selected their case to offer a corrective to the sanitized analyses of sex workers’ risk that use essentializing acronyms and assume that HIV is as important to the “target population” as it is to health researchers and policymakers.² Instead, the current work reminds us that these scenarios do not occur without emotion, just as behaviors associated with sex and addiction are not all irrational, meaningless acts of self-destruction.

However, all anthropological texts are interpretations and we acknowledge both the promise and the limits of ethnography in capturing and conveying emotional experience (Beatty 2010; Katz and Csordas 2003). Our interpretation is shaped by our identities as American female researchers who formed personal relationships through the course of the study. We agree with Peter Magolda’s (2000:230) sentiment that “qualitative researchers need not apologize for their subjectivity but must be aware of and acknowledge it” (Magolda 2000). While our account may differ from that of other researchers in this context, we were granted intimate access to Cindy and Beto’s home life that rendered our interpretations possible.

Ethically, building personal relationships with research participants who engage in illegal and stigmatized behaviors opens up difficult questions about representation and advocacy. In our personal interactions with Cindy and Beto, we attempted to navigate the blurry line between recommending referrals (e.g., to drug treatment and other services) and remaining respectful and non-judgmental of their drug use. Ethical questions linger after the field as well, including how anthropologists can best portray their subjects in a sensitive manner without stripping the rawness of their lives from the narrative. Through our scholarship, we aspire to clarify the structural factors that shape couples’ emotional vulnerability in an effort to advocate for broader social change (Denzin 2003), even as change remains difficult on an individual level.

Importantly, studying emotions in any setting is challenging given the debates surrounding biological, bodily, cognitive, and cultural interpretations of affective states and the impossibility of ever truly grasping the interiority of others’ emotional experiences (Leavitt 1996). In this case, studying Cindy and Beto’s relationship over time, paying attention to the broader context in which their relationship is embedded, and triangulating multiple data sources represents an honest anthropological attempt at understanding one couples’ subjective experiences of love and risk.

In conclusion, we find anthropological engagement with emotion to be a fruitful means of exploring complex issues like drug addiction among intimate couples. Especially important are considerations of differential meanings of “love” and emotional closeness in contexts of extreme structural vulnerability where such sentiments may appear implausible to our ethnocentric sensibilities, yet nevertheless are very real and carry significant consequences for couples’ health and wellbeing. As Margaret Mead reportedly once said, “Anthropologists ask for trouble when they deal with love because it is so hard to get a logical handle on it. But love is so incontestably important in human affairs that anthropologists who do not try flout the very definition of their profession” (see Sorenson 1995:1–8).