Sex work in Mexico: vulnerability of male, travesti, transgender and

transsexual sex workers

Cesar Infante*, Sandra G. Sosa-Rubi and Silvia Magali Cuadra
Center for Health Systems Research, Instituto Nacional de Salud Publica, Mexico
(Received 7 February 2008; final version received 22 August 2008)
In Mexico, male sex workers (MSW) and travesti, transgender and transsexual
(TTT) sex workers are among the groups most affected by HIV. They suffer from
stigma and discrimination, yet are often absent from the design of programmes
and HIV prevention campaigns. The objective of this study was to provide an
account of the social context in which MSW and TTT sex workers live, by
focusing on their sexual identities, sexual practices and vulnerability to HIV. Data
collection took place in Mexico City and involved observational work together
with 36 in-depth interviews. Findings reveal a differentiation of vulnerability by
sub-group. In general, vulnerability is influenced by the social context, stigma
related to homosexuality and sex work, as well as sex workers access to scarce
social capital and the lack of response in terms of social and health programmes.
In order to diminish the vulnerability of MSW and TTT sex workers and reduce
their risk of HIV infection, preventive measures are needed which take into
account their specific health and social needs, promote meaningful participation
and the encourage respect for human rights.
Resume
Au Mexique, les professionnels du sexe masculins, travestis, transgenres et
transsexuels sont parmi les groupes les plus affectes par le VIH. Bien quils
souffrent de stigmatisation et de discrimination, ils sont souvent absents des
processus de conception des programmes et des campagnes de prevention du VIH
qui leur sont specifiques. Cette etude visait a` decrire le contexte social dans lequel
ces professionnels du sexe evoluent, en se concentrant sur leurs identites sexuelles,
leurs pratiques sexuelles et leur vulnerabilite au VIH. La collecte des donnees a ete
effectuee a` Mexico, a` partir dun travail dobservation et de 36 entretiens en
profondeur. Les resultats reve`lent une differentiation de la vulnerabilite selon le
sous-groupe. Dune manie`re generale, la vulnerabilite subit linfluence du contexte
social, du stigma lie a` lhomosexualite et au commerce du sexe, ainsi que celle des
difficultes dacce`s au capital social auxquelles sont confrontes les professionnels du
sexe, et de labsence de reponses en termes de programmes sanitaires et sociaux.
Afin de reduire la vulnerabilite des professionnels du sexe masculins, travestis,
transgenres et transsexuels, et leur risque lie au VIH, des mesures preventives sont
necessaires, prenant en compte leurs besoins specifiques dans le domaine social et
dans celui de la sante, incitant a` la participation significative et encourageant le
respect des droits humains.
Resumen
En Mexico, los trabajadores sexuales masculinos (TSM) y los trabajadores
sexuales travestis, transgeneros y transexuales (TTT) pertenecen a los grupos ma s
*Corresponding author. Email: cinfante@insp.mx
Culture, Health & Sexuality
Vol. 11, No. 2, February 2009, 125137
ISSN 1369-1058 print/ISSN 1464-5351 online
# 2009 Taylor & Francis
DOI: 10.1080/13691050802431314
http://www.informaworld.com
afectados por el virus del sida. Sufren estigma y discriminacio n, sin embargo estan
ausentes en el desarrollo de programas espec ficos para las campan as de prevencio n
del sida. El objetivo de este estudio fue ofrecer un informe del contexto social en el
que viven los trabajadores sexuales TSM y TTT prestando atencio n a sus
identidades sexuales, practicas sexuales y vulnerabilidad al VIH. Se recogieron
datos en la Ciudad de Mexico y se llevaron a cabo un trabajo de observacio n y 36
entrevistas exhaustivas. Los resultados indican una diferenciacio n de vulnerabil-
idad en funcio n del subgrupo. En general, la vulnerabilidad esta influenciada por el
contexto social, el estigma vinculado a la homosexualidad y el trabajo sexual, as
como el acceso por parte de los trabajadores sexuales a escaso capital social, y la
carencia de respuesta en cuanto a programas sociales y sanitarios. A fin de
disminuir la vulnerabilidad de los trabajadores sexuales TSM y TTT y reducir su
riesgo de infeccio n del sida, son necesarias medidas preventivas que tengan en
cuenta sus necesidades sanitarias y sociales espec ficas, fomenten una participacio n
positiva y estimulen el respeto por los derechos humanos.
Keywords: HIV; travestis; transgender; transsexual; male sex workers; Mexico
Introduction
Since the first cases of Acquired Immunodeficiency Syndrome (AIDS) were reported
in 1981, human immunodeficiency virus (HIV) infection has reached pandemic
proportions. In Latin America, the HIV epidemic has largely affected men who have
sex with other men (MSM) (Caceres 2002, Sampaio et al. 2002). In Mexico
specifically, there is an HIV prevalence of 13.5% among men who have sex with men
(Centro Nacional para la Prevencio n y el Control del VIH/SIDA 2006).
In Mexico, there is growing concern about rising levels of HIV infection among
MSM as well as among travestis, transgender and transsexual (TTT) persons.
However, there is as yet little information on the distribution of HIV infection
among different sub-groups within these populations and even less is known about
its patterning among those individuals who sell or trade sex.
Previous studies of both male sex workers (MSW) and TTT sex workers have
been undertaken in Mexico and in other Latin American countries to describe the
different risks and vulnerabilities of each group. These studies suggest that the
differences depend on the money exchanged, sex workers social organisation, the
type of client and the context in which sex work takes place (Liguori and Aggleton
1998, Cuadra-Hernandez et al. 2004). Other studies conducted in Hispanic and
Latino communities, such as those of Belza et al. (2001) and Marin o et al. (2003),
conclude that HIV prevention programmes on sex work should be more specifically
adapted to the needs and circumstances of different groups of MSW and TTTs.
The World Health Organization (2005), the World Bank (1999) and UNAIDS
(2004) have all emphasised that key to slowing the spread of HIV are efforts to
strengthen the focus on reducing risk and social vulnerability among the most
affected social groups. In spite of this, MSWs and TTTs have been absent and
almost invisible in the design of public health policies in Mexico. As in many Latin
American countries, there are few specific strategies to prevent HIV infection within
these groups (Frasca et al. 2000, Piot 2000).
The main objectives of the present study therefore were to provide an account of
the social contexts in which MSW and TTT sex workers live, their sexual identities
and their sexual practices, while also identifying factors related to their vulnerability
to HIV infection in order to provide recommendations for the development of HIV
preventive strategies.
126 C. Infante et al.
Study design
This was a cross sectional study that combined a range of qualitative methods of
data collection, including observational research and in-depth interviews. An initial
literature review on sex work, vulnerability, stigma and discrimination informed the
construction of an interview guide. We conducted a pilot study to test the guide and
to firm up our data collection instruments. Data collection itself took place in
Mexico City.
For the main study, sample size was determined by convenience criteria (Robson
2002) and snowball sampling was used to expand the network of key informants over
time (Spradley 1980). To identify potential informants, we utilised mapping
methodology to identify MSW and TTT sex worker gathering points, i.e. places
where they tend to look for clients and provide sexual services. Interviews with key
informants within non-governmental organisations and the Centro Nacional para la
Prevencio n y el Control del VIH/SIDA (CENSIDA) helped identified potential
study sites.
In total, 36 individuals were interviewed divided into two categories. Within the
MSW category, men were classified according to the different types of sex work in
which they were involved: occasional sex workers, regular sex workers on the street
and regular sex workers who advertised on the Internet, in magazines and via
agencies. Within the TTT category, informants were divided according to the activity
that provided them with their main income: hairdressing, as performers in shows and
entertainers and sex work (see Table 1).
Informants were allocated to categories by members of the research team based
on the information provided. Data from sex workers who advertised their services
Table 1. Number of informants by type of sex work.
Type of sex workers interviewed
Male sex workers
Sex work site in
Mexico City
Regular (n) Occasional (n)
La Alameda and
La Zona Rosa
Men (both heterosexual and
gay) who work on the
streets. Some may be
living on the street (10).
Men who occasionally sell sex
and who do not depend
exclusively on sex work as
their main income (8).
Media workers Men who advertise their services
on the internet, through
agencies and in magazines (5).
Travestis-transgender-transsexual sex workers (TTTs)
Sex work site in
Mexico City
Regular Occasional
Insurgentes, Nuevo
Leon, Tlalpan
and Revolucion
TTTs working on the
street (4)
Hairdressers (4) Performers in
shows or entertainers (5)
Culture, Health & Sexuality 127
through the Internet and agencies are not included in the analysis, as we were not
able to collect enough information to strongly characterise this group.
Methods
Data were collected between November 2006 and May 2007. Fieldwork included
spending time in and around the places where sex work was offered. The sites
included five areas within Mexico City: the Zona Rosa, La Alameda park,
Insurgentes, Nuevo Leon, Tlalpan and Revolucion. All of these areas are located a
little to the south of the city centre. Through field observations, we were able to
document social interaction between sex workers and clients and through
observation and in-depth conversation we were able to gain insight into the social,
cultural, economic and political dimensions of these settings.
The analysis focuses on the following thematic areas: (1) informants perceptions
of their sexual and gender identity; (2) reported sexual practices and condom use; (3)
perceptions of HIV in the city; (4) housing, employment, education and health; (5)
access to healthcare including counselling and testing for HIV, treatment for sexually
transmitted infections (STIs) and treatment for HIV; and (6) stigma and
discrimination within the family, healthcare and employment. Individual interviews
lasted between one or two hours. All interviews were audio-taped and transcribed.
Although we knew that mistrust might limit how much informants would tell us
about their experiences, we worked closely with a local non-governmental organisa-
tion (NGO) that had previously worked with MSWs and TTTs in Mexico City. Some
of the people that worked with this NGO were community activists and were able to
introduce us to possible informants and helped us break the ice with the interviewees.
Each person interviewed was aware of the objective of the study and the
importance of his or her collaboration. We explained that our aim was to understand
more about sex work, the impact of HIVand AIDS in the city and issues of stigma and
discrimination. In order to undertake this study, we received the approval of the
Instituto Nacional de Salud Pu blic (INSP) ethics and research committees and
obtained the informed consent of each participant. When conducting interviews, it was
made clear that interviewees had the right to stop the interview at any time. Responses
were anonymous to respect confidentiality. We assigned a code number to each
interview and kept the list of identities separate from the transcripts and the tapes.
Data analysis
Initial analysis took place while the data was being collected. As a result, we were
able to identify a number of preliminary themes in informants discourse. We also
examined regularities, patterns and contradictions between different types of data
collected. The topical categories and descriptors employed by respondents were
systematically analysed. In order to enhance reliability, we discussed the coding
scheme, the development of themes, as well as the interpretation of the data,
regularly within the team and with colleagues at INSP.
Results
The main results of the study are summarised in Table 2. In this Table, sex workers
are characterised according to the context of sex work; specific social needs;
128 C. Infante et al.
Table 2. Characterisation of sex workers in Mexico City according to different forms of vulnerability.
Group Site Type of sex work Context and
vulnerability
Socioeconomic
status
Social networks
and capacity for
mobilization
Access to health care
and other social
programmes
Young men
living in the
streets
La Alameda Occasional
and regular
sex workers.
Living in the
streets in
deprived
conditions
(homeless and
jobless)
Low socioeconomic
status.
Survival networks
for access to food
and shelter.
Poor access to social
and healthcare
programmes
Drug and alcohol
use.
Diminished capacities
for formal
organisation.
Travesti,
transgender
and transsexual
sex workers
Insurgentes, -
Nuevo Leon,
Tlalpan and
Revolucion
Regular sex
workers.
Work on the
street in a
violent
environment.
Low to middle
socioeconomic
status.
Numerous conflicts
within this group.
Poor access to social and
healthcare programmes.
Occasional sex
workers who
are also
hairdressers
and/or who
may perform
in nightclubs.
Drug and alcohol
use.
Heavily stigmatized
and discriminated
against, even by
members of
the gay community.
A few have access to
private healthcare
practitioners.
Use of hormones
and surgery to
transform their
bodies.
Poor use of public health
services due to fear of
discrimination and lack
of confidentiality
Heterosexual
and gay men
Zona Rosa
and La
Alameda
Regular and
occasional
sex workers.
Work in the Zona
Rosa and in
Alameda Park.
Low and middle
socioeconomic
status.
Strong tradition of
social organization
and community
mobilization
within the gay
community.
Some access to private
healthcare practitioners
In Zona Rosa often
pay commission
to pimps.
Poor use of public health
services because of fear
of discrimination
C
u
l
t
u
r
e
,
H
e
a
l
t
h
&
S
e
x
u
a
l
i
t
y
1
2
9
organisation; and access to health services or other social programmes. In general
terms, we found that every group was vulnerable but that there were differentiated
risks for HIV infection. For example, in sites such as La Alameda the most
vulnerable group comprised young men both heterosexual and gay who lived on
the streets and for whom economic necessity made them less able to negotiate the use
of condoms. The vulnerability of other groups, such as TTT sex workers, was
determined by other factors. Travestis, transgender and transsexual sex workers
typically worked within a more violent environment and have specific health needs
related to the use of hormones and surgical procedures.
Socioeconomic characteristics and payment received
Male sex workers working in La Alameda were generally of low socioeconomic
status. Most had migrated to Mexico City from other states and did not have any
permanent place to live. Men in this area tended to stay with relatives, in hotels or on
the street and used the money from sex work to cover daily expenses. Travestis,
transgender and transsexual sex workers from Tlalpan and Insurgentes-Nuevo Leon,
on the other hand, were of middle-socioeconomic status. They charged considerably
more for each sexual service provided. Their mean income was between US$600 to
US$700 per week. They lived in permanent addresses and many had middle-class
aspirations such as buying a car, planning a vacation and moving to a better place.
Costs of sexual services varied according to where MSW and TTTs were based,
the method the client used to make contact sex workers, as well as the type of service
offered. Charges varied between US$20 and US$150 for penetrative sex. In places
such as the Zona Rosa, Insurgentes, Nuevo Leon and Tlalpan, the price for
penetrative sex started at US$50. However, in others, such as La Alameda park, the
price per sexual transaction was around US$25. The fees for oral sex were lower than
penetrative sex, ranging between US$5 and US$20.
The mean income per month for those working in La Alameda was between
US$150300, averaging about 45 clients per week. Informants reported having to
move from place to place on a regular basis to access more clients, with demand as
well as competition affecting mobility.
Sites and settings
La Alameda and the Zona Rosa
Both of these neighbourhoods are open public spaces located in the centre of Mexico
City. La Alameda is a city park and the Zona Rosa is a busy commercial and tourist
setting. Within La Alameda, there are numerous cultural activities such as street
performance, political demonstrations and informal commercial activities. Vastly
different social groups interact within the park, including middle- and working-class
families, tourists, traders, police officers, gay men, men looking for sex services and
MSW (either gay or bisexual). Male sex workers usually stand along park walkways
and around the fountains while waiting for a client. Typically they and the majority
of their clients, have a low socioeconomic status. Generally, there is a sense of safety
in and around the park and no violent incidents were reported during this study.
130 C. Infante et al.
The Zona Rosa is a middle- to high-class neighbourhood. For many years, it has
been a gay gathering centre with many gay bars, clubs, discotheques and shopping
centres. In the Zona Rosa, sex work is most frequently conducted on Hamburgo Street.
Similar to La Alameda, sex workers stand in the street and wait for clients.
Negotiations occur on the spot and then they go to a nearby motel, hotel or car. In
contrast to La Alameda, the majority of MSW in the Zona Rosa are gay men, with
TTTsex workers forming a minority. According to the interviewee, a number of pimps
control MSW in the Zona Rosa and charge them a fee for working on the street.
Male sex workers in La Alameda and in the Zona Rosa vary in age between 16
and 26 years. They have generally completed between three and nine years of formal
education and come from a low socioeconomic background. In general, they do not
have large families to support since they usually live alone, with their families or with
other friends. Only a few interviewees mentioned that someone else was economic-
ally dependent on them, most typically their partner or mother. Men in this group
typically reported having their first transactional sexual experience had been around
between 14 to 20 years of age and their sexual identities varied from bisexual to gay.
Some had regular female partners with whom they lived.
Male sex workers working in La Alameda and the Zona Rosa came from
different parts of Mexico. Typically, they had arrived in Mexico City after running
away from home because of abuse and (for those who were gay) discrimination
within their families and local communities. Some had stayed with relatives, but had
found themselves facing the same discrimination and stigma they suffered in their
home communities:
I decided to leave my family because my uncle sexually abused me. I am gay and that
caused me a lot of problems and [so I] decided to come to Mexico City. I arrived here to
live with relatives and as soon as my uncle noticed that I was gay he kicked me out. I
arrived here in La Alameda because of my friends and I work because I need the money.
(MSW in La Alameda)
When on their own, they would find others in their similar situation through friends
and the people they met in gay clubs, bars or at college. At first, they went out to
meet people, but eventually got involved in sex work. Some provided sex in exchange
for money or gifts. However, many reported that they did so in order to fulfil their
own emotional needs. Some had traditional jobs in local markets and stores, but
wages were low, so sex work was used to supplement their income.
Sex work among men in La Alameda tended to take place in restaurant toilets, in
cars, hotels or within the park itself. Some young men appeared to have an
arrangement with hotels where they could stay overnight if they brought their clients
back. According to their testimonies, many MSWs preferred to work in La Alameda
because they felt more secure and did not have to pay for protection or to work.
The MSWs generally did not disclose their activities as sex workers to anyone
because of stigma related to homosexuality and to sex work:
I think I am heterosexual because I like women, but maybe I am homosexual because I
have sex with men, but I like women. I even have a girlfriend and also I am going out
with another girl that works around here. They do not know that I am a prostitute. If
they knew, I am sure they would not talk to me again. If my mother knew, I would kill
myself. (MSW in La Alameda)
My mother and my sisters know that I like other men but they do not know what I do to
get money (sex work). I do not want my uncles and friends to know that I like other
Culture, Health & Sexuality 131
men. They would reject me and I would never see them again. They would not invite me
to play football any more. (MSW in La Alameda)
The sexual services informants provided tended to vary according to sexual identity.
In the La Alameda, many heterosexually-identified MSWs considered themselves to
be men and reported that they were active in sexual anal intercourse and received,
but did not give, oral sex to clients:
Part of what I do is to receive oral sex and to let the client masturbate me. I may kiss them
but I never give oral sex to the client or let them penetrate me. (MSW in La Alameda)
Sex workers who identified as heterosexual arguably felt they would be less
stigmatised and discriminated against for their behaviour than would be men who
self-identified as gay. Many men considered playing an active role when having
anal sex with another man as an accepted normality that did not call into question
their masculinity.
In La Alameda, there was evidence of drug and alcohol use among MSWs. Many
men drank beer and smoked marihuana; and a few inhaled solvents and glue.
Around 30 young MSWs had established an informal network that helped them
access food and shelter. The group had an arrangement with two or three hotel
owners in La Alameda. If they brought their clients to these hotels, they were allowed
to stay overnight.
Insurgentes, Nuevo Leon and Tlalpan
Insurgentes and Nuevo Leon are two city streets located in the centre-south of Mexico
City. In each of these areas, we recruited a number TTTs participating in sex work.
The mean age of the TTT informants was 24. Typically, informants were middle-
class, based the amount of bodily transformation they had undergone and the type
of clothes they wore. They tended to stand along these two streets waiting for their
clients, who also appeared to be middle-class, judging by the cars they drove.
Negotiations for sex tended to take place in the street and once a price had been
agreed, the sex worker would get into the clients car so they could drive to a nearby
hotel.
Tlalpan is another area located in the south of Mexico City. Sex work occurs
along a five-to-eight kilometre stretch of the main street. In this area, women sex
workers and TTTs occupy different locations on the street. There are numerous bars,
cantinas and hotels in this section of Tlalpan. The majority of sex workers can be
found around the hotels, where the demand for sex is high. The socioeconomic status
of clients and sex workers vary considerably in this area, as does the degree of
economic investment in appearance and physical transformation among members of
TTT group.
Even with continuous police round-ups, this is not a secure area of the city, with
pimps controlling different groups of sex workers. According to the testimonies
elicited, sex workers must pay a pimp in order to work and sometimes they even have
to physically fight and win their right to work in the street. In order to work in the
main two blocks, TTTs have to appear beautiful and invest money in their
appearance and their body.
Travestis, transgender and transsexual informants were between 21 and 44 years
of age and the majority came from a low-socioeconomic background. Interviewees
132 C. Infante et al.
had between 9 and 12 years of formal education. They came from different states
across the country, mainly rural communities, to Mexico City looking for a better
life. Typically, TTTs involved in sex work also worked in hairdressing, as
entertainers in shows or in bars.
Travestis, transgender and transsexuals were more likely to have a regular
partner than MSWs and none reported having economic dependants. Two TTT
informants knew that they were living with HIV and were receiving care and
antiretroviral treatment. Physical abuse, including abuse by family members, was
also reported within this group. Informants reported having their first transactional
sex experience between 14 and 16 years of age and all described their sexual identity
as homosexual, whilst their gender identity varied from hombres muy afeminados or
feminine men to mujeres completas or complete women.
Travestis, transgender and transsexuals are commonly rejected and suffer stigma
and discrimination even fromthe gay community. Many gay men equate being a TTTto
being a thief or a drug user. One of the most important problems TTTs identified was
that arising when their legal documents did not match their perceived self-identity:
In any legal document I am a man and I accept that, but I also perceive myself as having
a female identity. I would like be a woman. So I feel like Im living on the edge. (TTT
hairstylist and occasional sex worker)
According to interviewees, TTTs experienced constant physical and emotional violence
while selling sex in the street. There is little feeling of belonging to a specific social group:
We face discrimination because we are feminine men and other gay men do not
understand that. They reject our femininity. There is also a lot of envy between travestis,
transgender and transsexuals. The envy is because one is more beautiful than the other
and may have more clients and gain more money. (TTT in La Alameda)
There is a lot of machismo since men do not like a man that dresses as a woman. Some
may laugh at us. I have been beaten up in the street and discriminated against even by
the gay community. I was put in jail because I was accused of stealing in a grocery store.
The owner did not want me hanging around the area and he lied about me being caught
stealing. I was raped by the police and the prison officers, they cut my hair and beat me
up badly. (TTT hairstylist in Zona Rosa)
Travestis, transgender and transsexual sex workers experience worse violence than
MSWs, although those who work in bars and clubs or in beauty salons were to a
degree protected. Members of the group face violence, abuse, unemployment,
discrimination within their homes, stigma within the wider community and difficulty
establishing supportive social networks. Their social trajectories varied. Some might,
at a particular time in their lives, be both performers in shows or entertainers and sex
workers. Others may have started off as sex workers but become hairstylists at the
time of the study. TTT informants said that becoming a hairstylist or owning a
beauty salon was a signal of success since they would not have to work in the streets
again. Nevertheless, TTT hairstylists told us that they missed the glamour and
competitiveness to get greater numbers of clients. At the same time, however, the
beauty salon could be a safer place to have sex.
Condom use and preventive strategies
In interview, both types of sex workers indicated that condoms were used in the vast
majority of transactions, particularly when the service included penetration. They
Culture, Health & Sexuality 133
also mentioned consistent refusal on their part to have penetrative sex if the client
did not want to use a condom or if a condom was not available. We did not find
anyone who said that they had been forced to have sex without a condom. However,
there was mention of other sexual practices, such as oral sex, where a condom was
not used regularly:
I know that condoms protect against STDs and HIV, but I like to receive oral sex
without a condom. If I see that his penis is dirty then I use a condom, but if the client
looks clean then there is no problem. I do not like condoms because of the taste of latex.
(MSW in La Alameda)
In the past I tried to use a condom every time I had sex but sometimes I didnt use one. I
didnt use condoms for oral sex. If the client looked clean I didnt always use a condom
for penetrative sex. But now I have more information and I use condoms for everything.
(TTT sex worker in Tlalpan)
Some informants mentioned masturbation as a safe practice and a strategy to have
more clients and to protect against HIV and other STIs:
When performing oral sex I might doit correctly at the beginning, but when the client starts
enjoying it, I will start talking to him and I will masturbate him. Also when having sexual
intercourse I close my legs sothat the clients penis does not reachmy anus. Basically he will
be fucking my legs. These are strategies for me. (TTT who does performances and
occasional sex work in Tlalpan)
Although most MSWs knew they should be using condoms, they actually used them
inconsistently. Included among the factors related to this was lack of information
about the risks of different sexual practices. A great majority of MSWs mentioned
that the practice of oral sex without the use of condom was a safe sexual practice.
Young sex workers were particularly poorly informed. Unsafe sex could be
associated with higher fees and was therefore more popular among sex workers in
more economic need. Finally, trust in ones partner could lower the likelihood of
consistent condom use.
Beyond the issues highlighted above, informants had difficulty meeting their
basic needs for food, housing, employment, education, healthcare, HIV testing with
pre- and post-counselling and access to condoms. When they had a health problem,
they tended to go first to friends and then to a private practitioner, since typically
they did not have access to other types of healthcare service. To get an HIV test,
most male sex workers went to a private practitioner. They did not use the public
healthcare services because they did not believe doctors and nurses working in public
health centres would respect their confidentiality. They said they did not feel
comfortable in talking to public sector doctors.
Male sex workers and TTTs in all situations did not remember being given
information about HIV prevention or free condoms by either public health services
or NGOs. They had to buy their own condoms and felt that the information
recovered was insufficient. Risk perceptions were high, with informants believing
they were at risk of acquiring STIs and HIV because of their sexual practices. They
recognised that they were living in a violent and marginalised community and that
this determined many of the bad things that had happened to them. Men working
in La Alameda felt that they deserved more help since they suffered from hunger and
did not have a home, schooling or a proper job. They practiced sex work because
they needed the money to live:
134 C. Infante et al.
At the beginning I started to sell sex because I liked it. I am gay and have accepted my
sexual preference and I wanted to be in this environment and to be paid for having sex.
This was nine years ago and now I have tried to stop doing it. I had a partner and we
were OK, I was working and we were having a good time. Unfortunately we broke up
and now I need some more money and have started selling sex again. There are many
times when I even feel sick of myself and my body because of being a puto. (MSW in La
Alameda)
For TTTs, another important health need was the need to buy oils and hormones.
Many TTT use them incorrectly, take inappropriate doses and damage their skin and
muscles by injecting oil. At the time of this study, we could not identify a single
official governmental health service that engaged with the health needs of TTT sex
workers.
Discussion and conclusions
Numerous studies of HIV-related risk among MSM have pointed to individual
factors that lead to unsafe sexual behaviour (Rotheram et al. 1992, Carballo-Dieguez
1996, Pharr 1997, Shifter and Madrigal 1998, Toro Alfonso 2000, Dilorio et al.
2002). However, recent developments encourage us to analyse vulnerability to HIV
by focusing on questions of race/ethnicity, social class, gender power, stigma and
discrimination, among other factors (Parker and Aggleton 2003, Gupta et al. 2008).
In this study we have tried to identify social, cultural and socioeconomic factors
associated with vulnerability to HIV infection. They include a whole range of
structural factors that make MSWandTTTsex workers particularly vulnerable toHIV
infection. They include the context where sex workers work, the stigma and
discrimination related to sex work, the violence enacted towards TTTs, the low levels
of social and legal support and the limited access to healthcare that sex workers have in
Mexico City. Young park-based MSW were more vulnerable to HIV infection than
other groups of sex workers because they are jobless, homeless, have only a fewyears of
education and needed money to purchase alcohol and drugs.
Although we tried to typify a range of MSW and TTT sex workers in Mexico
City, we were not able to gain access to some particular sex work settings, such as
massage parlours and public baths. Male sex workers located in these locations were
not willing to be interviewed. We also had limited success in gaining information
about specific sexual practices among the different groups of sex workers. Thus, we
did not have enough information either to characterise the complete range of MSW
and TTT sex work as we had hoped or to describe the specific risks different kinds of
sex workers faced.
What was noticeable, however, was the complete absence of healthcare services
directed to both MSW and TTT sex workers. Neither group had access to health
services, health information about risky sexual practices or specific strategies to
negotiate condom use with clients, HIV/STI testing or counselling and health
services for treatment and control of HIV/STIs. Additionally, TTT sex workers did
not have access to access to health services relevant to their health needs arising from
the inappropriate use of hormones and oil.
Several sex workers mentioned that they had been forced to move from their
hometowns in Veracruz, Morelos, Puebla, and Oaxaca to Mexico City because of the
stigma they faced within their places of origin, particularly the discrimination
enacted upon them by their families. The most common forms of discrimination they
Culture, Health & Sexuality 135
had experienced were social rejection, isolation, gossiping and even physical abuse
and sexual violence. Some young men had difficulties settling down in Mexico City
because of their lack of social networks within the city. Although some have been
able to develop survival networks with other young men, particularly those who
work in La Alameda, they still did not have access to healthcare, food, housing and
employment.
Travestis, transgender and transsexual sex workers were the group most affected
by stigma and discrimination. They reported multiple instances of physical and
psychological abuse, not only at the hands of their clients and the police, but also
from other MSW and the gay community. Their visibly different appearance and
body transformation made them more vulnerable to violence and abuse in the
streets.
Despite condom use in many transactions, young MSW in this study were
inconsistent in their use of protection. This was the result of their limited knowledge
about the risks of specific sexual practices, their lack of experience in sex work and
their economic need. This finding relates to other studies that conclude that the
practice of unprotected sex is linked to low-socioeconomic status, trust in regular
sexual partners, vulnerability due to young age, the use of injection drugs, low levels
of social support and a lack of condom availability (Peterson et al. 1992, Carballo-
Dieguez and Dolezal 1996, Colby 2003, Dandona et al. 2005).
Among sex workers interviewed, however, young MSW showed the greatest
willingness to participate in an HIV-prevention programmes. They had more
receptive attitudes and tended to feel that they could benefit from regular attendance
of prevention counselling sessions and from HIV/STI tests. In contrast, older MSWs
and TTTs showed less interest in participating in such activities. This offers hope for
the future but points once more to the need for a differentiated and fine-grained
response that takes account of different circumstances and needs.
Only when consideration is given to the specific structural vulnerabilities of
MSWs and TTT sex workers will we be able to implement appropriate HIV-
preventive programmes. Limited access to healthcare, preventive information and
condoms; lack of social support from families and community; the absence access to
of legal services; ongoing stigma and discrimination; and sexual exploitation and
trafficking heighten the vulnerability of members of the groups we have reported on
here.
Acknowledgments
Special thanks to Tyler Martz, Paul Tyrer and Marta Caballero for their editorial assistance as
well as for suggestions for improving the argument.
References
Belza, M.J. et al. 2001. Sociodemographic characteristics and HIV-risk behaviour patterns of
male sex workers in Madrid, Spain. AIDS Care 13, no. 5: 677682.
Caceres, C.F. 2002. HIV among gay and other men who have sex with men in Latin America
and the Caribbean: a hidden epidemic? AIDS 16, no. 3: S23S33.
Carballo-Dieguez, A., and C. Dolezal. 1996. HIV-risk behaviours and obstacles to condom
use among Puerto Rican men in New York City who have sex with men. American
Journal of Public Health 86: 16191622.
136 C. Infante et al.
Centro Nacional para la Prevencio n y el Control del VIH/SIDA. 2006. El SIDA en cifras
(2006). Available from: http://www.salud.gob.mx/conasida/ [Accessed 20 May 2008].
Colby, D. 2003. HIV knowledge and risk factors among men who have sex with men in ho Chi
Minh City, Vietnam. Journal of Acquired Immune Deficiency Syndromes 32: 8085.
Cuadra-Herna ndez, S.M., R. Leyva-Flores, D. Herna ndez-Rosete, and M. Bronfman-
Pertzovsky. 2002. The inclusion of human rights in AIDS/HIV norms in Mexico and
Central America, 19932000. Salud Publica de Mexico, no. 44: 508518.
Dandona, L. et al. 2005. Sex behaviour of men who have sex with men and risk of HIV in
Andhra Pradesh, India. AIDS 19: 611619.
Dilorio, C., T. Hartwell, and N. Hansen. 2002. Childhood sexual abuse and risk behaviour
among men at high risk for HIV infection. American Journal of Public Health 92:
214219.
Frasca, T. et al. 2000. Needs assessment for HIV prevention among gay and bisexual men in
three provincial capitals of Chile. Presentation at the 13th International Conference on
AIDS, July 2000 Durban, South Africa. Abstract TD736.
Gupta, G. et al. 2008. Structural approaches to HIV prevention. Lancet. Available from:
DOI:10.1016/S014-6736 (08)60887-9 [Accessed Aug 6 2008].
Liguori, A., and P. Aggleton. 1998. Aspectos del comercio sexual masculino en la ciudad de
Mexico. Debate Feminista 9, no. 18: 152185.
Marin o, R., V. Minichiello, and C. Disogra. 2003. Male sex workers in Co rdoba, Argentina:
sociodemographic characteristics and sex work experiences. Revista Panamericana de
Salud Publica 13, no. 5: 311319.
Parker, R., and P. Aggleton. 2003. HIV and AIDS-related stigma and discrimination: a
conceptual framework and implications for action. Social Science & Medicine 57: 1324.
Peterson, J.L. et al. 1992. High-risk sexual behavior and condom use among gay and bisexual
African-American men. American Journal of Public Health 82: 14901494.
Pharr, S. 1997. Homophobia: a weapon of sexism. Berkeley, CA: Chardon Press.
Piot, P. 2000. Report by the Executive Director, Programme Coordinating Board. Joint
United Nations Programme on AIDS. 1415 December Rio de Janeiro.
Robson, C. 2002. Real world research. Oxford: Blackwell.
Rotheram-Borus, M.J., H. Meyer-Bahlburg, and C. Koopman. 1992. Lifetime sexual
behaviors among runaway males and females. Journal of Sex Research, no. 29(1): 1529.
Sampaio, M. et al. 2002. Reducing AIDS risk among men who have sex with men in Salvador,
Brazil. AIDS and Behavior 6, no. 2: 173181.
Shifter, J., and J. Madrigal. 1998. Las gavetas sexuales de los jovenes costarricenses:
implicaciones para la prevencion del SIDA. San Jose, Costa Rica: Editorial ILPES.
Spradley, J. 1980. Participant observation. New York: Holt, Rinehart and Winston.
Toro-Alfonso, J. 2000. El desarrollo de una intervencio n para la prevencio n del VIH para
hombres homosexuales en Puerto Rico: un modelo para el Caribe. Inter-American
Journal of Psychology 34: 1731993.
UNAIDS. 2004. Report on the global AIDS epidemic (4th global report). Geneva, Switzerland:
UNAIDS.
WHO. 2005. Report on the global HIV-AIDS situation. Aids epidemic updates 2005. Available
from: http://www.who.int/hiv/epiupdates/en/index.html [Accessed 18 March 2007].
World Bank. 1999. Confronting AIDS: public priorities in a global epidemic. New York: Oxford
University Press.
Culture, Health & Sexuality 137