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Revista Colombia Médica, Vol. 38, No. 3 , Jul./Sep. 2007, pp. 237-250 Market and risk: stages of hiv transmission among men with homosexual behaviors. Medellín 1993-2006 Mercado y riesgo: escenarios de transmisión del VIH entre hombres que tienen sexo con otros hombres. Medellín, 1993-2006 Isabel Cristina Posada, Psicol., M.S.P.1, Rubén Darío Gómez-Arias, M.D., M.S.P., Ph.D.2 1. Profesora de Cátedra, Facultad Nacional de Salud Pública, Universidad de Antioquia, Medellín, Colombia.
e-mail: icpz@guajiros.udea.edu.co Recibido para publicación septiembre 21, 2006 Aceptado para publicación julio 4, 2007 Code Number: rc07045 SUMMARY
Background: People’s different responses to HIV prevention programs have been related to collective patterns of significance that are imposed to their behaviors, and affect the success of health interventions. Keywords: HIV; Risk; Harm reduction; Homosexuality; Life style; Qualitative research; Risk reduction behaviour. RESUMEN
Introducción: Las diferentes respuestas de los individuos a las medidas de prevención para VIH se han relacionado con patrones colectivos de significación que se imponen al comportamiento y que influyen en el éxito de las intervenciones. Palabras clave: VIH; Reducción del daño; Homosexualidad; Estilo de vida; Investigación cualitativa; Conducta de reducción del riesgo. In spite of the promising results of Highly Active Antiretroviral Therapy (HAART) for people with HIV, neither vaccination nor a cure for the infection is available. Prevention continues to be the most realistic strategy; and one of the biggest restlessness in the entire world tours around the effectiveness of the educational programs to prevent the dissemination of HIV (1,2). Studies related with this aspect suggest that the people’s different responses to preventive programs can be related to learning determinants, particularly to personal conditions of psychosocial development, and to collective patterns of significance and social control, which are imposed to the individual behaviors (3-5). The question has derived towards an understanding of risky behaviors. To this respect, the preventive focuses have been built with concepts and paradigms coming from the social sciences and from current ideologies, especially from the rational consumer’s paradigm (RCP), which prevails in the mercantile society. This model supposes that, when facing potentially harmful situations, human beings behave like well informed consumers, interested in their personal protection, able to identify the risks and to manage them effectively (6-8). The RCP assimilates in an eclectic way, different concepts coming from the psychology and the sociology, and pushed by globalization, it has impregnated the social management foundations in most countries. In the health field, the RCP has been incorporated to the sanitary speech, making individual responsibility (self efficacy) the central factor to intervene in the health-disease process (4,9,10). This ideological commitment is particularly significant in connection with HIV, where the RCP is usually observed as an articulating point in the discourses of the general population, the people affected by the epidemic, and the experts themselves. Influenced by the RCP, the preventive focuses frequently assume that our behavior resembles that of a rational Anglo-Saxon man, aware of his risks, concerned by his personal security, free to make decisions (4,5), as well as, responsible for preventing HIV transmission and for assuming the consequences of his actions, among them the cost of the necessary services and treatments. According to this model, the free decision-making of each person is limited only by his ignorance and self efficacy, and it is there where preventive focuses have to be centered (3,11). Some studies suggest that preventive programs based on the informed RCP, not only misunderstand the social influence on one’s behavior and the responsibility of the State about risks, but rather they have increased people’s vulnerability, limiting the range of opportunities they have to access more effective options (12-14). Researchers that study human behavior don’t always coincide about personal responsibility. Contrary to the ideas that emphasize the role of the individual conditions in decision-making, other focuses highlight the importance of the atmosphere and the social environment on our behavior. From sociology, the symbolic interactionism proposes that human beings tend to modify their patterns of usual behavior according both to roles that we carry out in different places (scenarios), and to the interaction with other people around us (public) (15). From this focus, the actors assume particular roles according to librettos or scripts generated by the public’s expectations with which they interact, in scenarios that are at the same time determinants and a result of the social interaction. According to these debates, the understanding of t behavior patterns developed by people to manage their risks emerges as a key element for health policymaking and particularly for those related to HIV control (3,16). This aspect has being studied since 1990 by the National School of Public Health of Medellín. Between 1993 and 1996, in cooperation with the Sectional Direction of Health of Antioquia DSSA, official agency responsible for the public health in the state, and the Non-Governmental Organization (NGO) Positives for Life, qualitative investigation was carried out with the intention of characterizing social and cultural processes that could increase the transmission and sexual acquisition of HIV in the region. The study was bounded to the Metropolitan area, around Medellín, since there concentrates more than 52.1% of the population of the state, and the biggest number of cases of HIV infections registered in the region. This article is the result of an investigation carried out by the investigators between 1993 and 1996, and upgraded in 2006 with the specific objective of improving the understanding of the collective conditions in which MSM carry out their risk management. MATERIALS AND METHODS The first phase of the study began in 1993. The epidemiologic registers available for the region were revised with the purpose of obtaining information that could help to profile the epidemic and the population groups with higher risk (17,18). According to this information five population groups were identified because their higher risk of sexually transmitted HIV. One of these groups was that of men who have sexual contacts with other men (MSM). In order to understand the psycho-social dynamics of the risk management in these selected groups, a qualitative methodology was applied, from a focus where the principles and techniques of the symbolic interactionism prevailed. The project considered that not all the behaviors acted out by the groups of interest expose them to a bigger infection risk, but only some of their sexual practices (19-21) and some of the representations (knowledge, emotions, attitudes, codes and values) which support them (19,22-25). These representations can be the key in the way people face situations of risk and apply preventive measures. In connection with the psycho-social dynamics of their risk management we defined five central categories of analysis: a) management of scenarios of risk, b) subjective experiences while facing the dynamics of the epidemic, c) management of infection risks, d) management of personal development and e) understanding of prevention and treatment health services. This report deals only with one of the components of the study: the management of risk scenarios of HIV sexual transmission for MSM. Selection of scenarios. Not all scenarios that make-up the material and social world of the selected groups were considered reference contexts for the observation, interpretation and validation of meanings. In the different municipalities of the Metropolitan area of Antioquia, the study selected as risk scenarios of HIV sexual transmission, only the places open to the public where the actors meet to carry out activities that could increase their probability of sexually getting or transmitting HIV, or that could facilitate the application of individual or group protection measures. By means of exploratory focal groups with people linked to the HIV control programs in the region, we identified the following scenarios, which were later used to meet the speakers: 1. Meeting places where the promotion, selection, offers and demands of sexual activities occur as commercial exchange (places where «hooking up» or sexual encounters occur for exchange of money). 2. Meeting places where individuals look for sexual encounters or they offer sexual intercourse without payment mediation (places where «hooking up» or sexual encounters occur without mediation of money). 3. Meeting places where individuals play out the characteristic activities of their subculture, with intentions other than sexual intercourse (clubs, recreation and fun places, centers for personal and cultural development). With the help of members of the NGO, the map of scenarios of risk for each group was raised; the mapping included the address and nature of the establishments, their rates, their schedules and the characteristics of their customers. As a first step, scenarios were identified and described before any communication with the actors took place. Among similar scenarios, those identified by the mapping as the more representative of the group were visited. Selection of informants. Representative individuals of the selected groups of interest were interviewed in the previously defined scenarios. The contact with the informants was established in a personalized way, by the investigators and by some members of the NGO whose knowledge, access, or identification with the characteristics of the members of the target populations made possible a good communication. The information was obtained by means of field visits to the scenarios of risk in its moments of higher activity, and included semi-structured and in-depth interviews with actors present at the scenarios who freely accepted to participate in the study. The representativeness of the speakers was set based on the role that each individual played in the selected scenario; that is, it was set in accordance with expressions and explicit manifestations of the person present at the place which reflected directly or indirectly his identity with the codes and values of the scenario, and which led to consider him a reliable informant about the motivations and experiences that usually take place there. The investigation assumed a strict ethical code directed to guarantee the informed consent, the protection, and the anonymity, not only of informants but also of investigators who were forbidden to make any references to the discoveries, outside of the validation meetings and of the elaboration of reports. Each one of the interviewers visited the selected scenarios in repeated occasions with the purpose of contacting representative informants. Recordings, field notes and anonymous life histories, were raised based on dialogue structures and common approaches defined by all the investigators. At the end of the study 100 people in the higher risk groups were interviewed; among them 39 were MSM. This material was object of a second analysis and systematization by the main investigators, with the purpose of specifying the achievements of the study, to formulate preliminary interpretations and to propose the pertinent measures of intervention. Later on, meetings were carried out for analysis and validation with those informants contacted previously from the scenarios who accepted to participate. Nine group meetings for validation were registered; in each meeting between 6 and 12 speakers participated. The meetings emphasized the triangulation and consensus of the stories proposed by investigators according to the first analysis. From these meetings, reports were written and recorded, with the participants’ authorization. The first phase of the study finished in 1996 and it served as base to formulate the sanitary policies of the DSSA in office at that time. In 2006 the study was upgraded for MSM, by means of focal groups, in order to detect variations in the scenarios and actors that could suggest, for the studied population, changes in the dynamics of the sexual HIV transmission or in its control policies during the period. RESULTS The study identified three types of scenarios in the region where MSM exercises their identity and sexuality, and at the same time where they face the risks of acquiring sexually transmitted diseases (STD) such as HIV: 1. Scenarios for «hooking up» (sexual encounters). 2. Scenarios of genital contact. 3. Scenarios of personal development. Although the three types of scenarios present marked differences among each other, frequently they converge in the same place at different moments of the day, and depending on the rules that the actors impose in agreement with certain conditions of the scenario. The study was able to identify in the metropolitan area, 8 types of scenarios which enjoy special acceptance among HSH: 1. Bars, dance clubs and the like. 2. Turkish bathrooms and saunas. 3. Public roads. 4. Parks. 5. «Cycle-roads» 6. Lavatories of commercial centers 7. X-rated movie theaters. 8. Internet cafes. For each scenario the characteristics of the physical space, the actors, and the roles they play are described; these three elements, however, are indivisible and, in practice, they are integrated and they transform mutually when configuring each scenario. 1. Bars, dance clubs and similars. Bars, dancing places and taverns, constitute an important scenario for MSM where they practice basically recreational and personal development activities. Secondarily, they are scenarios of «hooking up» and in some cases of genital contacts. The description of this scenario was obtained by consent among the observations of six of the investigators who visited the scenarios. The places that serve as bars and the like are very different from each other. The type of music, the location of the place, the illumination, the decoration and the rates of attendance, are the main variable factors that contribute to segmentation of the clientele and to the configuration of the scenario. In all the municipalities included in the study, there were bars and the like visited by a heterogeneous population of both sexes, but this did not exclude MSM from also visiting these places. The places that were exclusively for homosexual males, which used to be rare in the studied region in 1993 (56 were identified in the whole area) have increased greatly in the area during the last years. None of these establishments is announced to the public as a place where gay customers go; however their clients get there by information obtained from other customers (mouth-to-ear publicity) or by means of business cards the establishments distribute. In general, these places are small and slightly dark, where we could define 4 important spaces to study: the bar, the tables, the lavatories and the entrance door.
Each establishment has its attractiveness and its clientele defined primarily by the type of music and by the atmosphere that the other clients generate. Some are exclusive for males with homosexual tendencies, although more and more frequently they are being visited by bisexuals and heterosexuals men and women who feel comfortable to a different degree with the rules of the house. The decoration and interior cleanliness of the places are varied. Some of them exhibit posters and paintings of nude male and erotic scenes. The hygiene, the good taste and the quality of the attention are values of the place that are related with to the social status of the clientele and the money they’re willing to pay. The actors of these types of scenarios are male older than 18, of different socioeconomic status who attend by groups or couples searching social interaction, company, recreation and, in some cases, sex. Over the last years, the proportion of young clients who go looking for a sexual exchange with older men that are willing to pay-with money or valuables- for genital contacts has increased in these types of scenarios; the fellows involved in this erotic and commercial exchange usually have their own heterosexual couples. This type of situation could partially explain the observed increment of monogamous women in the region who have been infected by their partners (26). In these scenarios certain values are considered: the music, the decoration, conversation ability, the consumption of drugs and alcohol, physical beauty, the youth, sexual character and informality. The tacit rules of the scenario can insinuate and stimulate the erotic contact, but don’t allow neither genital contact nor nudity among clients. The interactions with sexual intentions are covertly carried out, far from the public’s view, using subtle verbal and non-verbal codes. Some scenarios have reserved areas that favor intimate sexual contacts; these can also take place in mutual agreement at the rest rooms. The recreation these places offer is characterized by the audition of different types of music, conversation, consumption of alcohol in varying degrees, and sexual encounters. The consumption of psychoactive drugs is relatively frequent, and although it is recognized by the staff as well as by the clients, it is nevertheless carried out in a hidden way. The excessive consumption of alcohol and psychoactive drugs is also a fundamental condition of the scenario and it‘s implicitly accepted by the actors, thus, several of the decisions that the actors make in this scenario can be affected by the effects of the alcohol and/or other psychoactive drugs consumed, especially after midnight. Some of these places offer «striptease» shows performed primarily by young students; after the show, the client can negotiate with the dancer a later encounter outside of the establishment. Dance clubs also offer the actors the possibility to dance with other clients, and this activity is recognized and valued as an opportunity of recreation, communication, affection and personal development. The physical contact through the dance can constitute in itself an erotic stimulus and favor the later performance of other types of interaction. Although customers use to visit bars and dance clubs with couples or friends, these scenarios are also important places for «hooking up». The mechanisms for «hooking up» can be very similar to those that happen in places for heterosexuals. It is frequent that, in these places, the stability of a homosexual couple is put to a test: «you can go dancing… you can see somebody who impacted you; and even if you are with your partner, if that person gives you the opportunity, you give him your phone number, and behind that phone number comes the infidelity», some of the interviewees affirmed. Many of the clients are in a constant search for «…something that I can’t find…». The attendance in couples and groups, and the consumption of alcoholic drinks, favor the occurrence of fights and disturbances that are less common in other scenarios studied, such as the Turkish bathrooms and saunas. Bars and dance clubs are also scenarios for socializing and reinforcing of identities. The clients go there looking for communication with their partners and for reinforcing their subculture. In this respect, the interviewees relate that «people go to the gay bar because a special experience can be lived there»; contrary to the public bathrooms and other scenarios created by and for MSM «a cultural identification with homosexuality takes place among the people that attend these places...». The tension that is created by the feeling of surviving in a society that is hostile to homosexuality can be muffled in a scenario that, legitimizes it and additionally, offers the uninhibited and euphoric effects of alcohol and psychoactive drugs. Although bars and dance clubs are part of the rumba, this doesn’t always finish there. Contrary to the sexual contacts that are given in other MSM scenarios, genital contacts, which can originate in bars and dance clubs, are often influenced by the effects of the alcohol and the rumba atmosphere taking place there. 2. Saunas and turkish bathrooms. The description of this scenario was obtained by consent among the observations made by 13 of the investigators that visited them to carry out the interviews. In all the municipalities included in the study, there where bathrooms (saunas and Turks) open to the public and visited by a heterogeneous population of both sexes, and also by MSM. In 1993, the study was able to detect in the Metropolitan Area, 14 public bathrooms, 9 of which were scenarios of «hooking up» and of sexual activities for MSM; these recreation places have been described thoroughly in other countries like scenarios of high risk to acquire sexually transmitted diseases (STDs) (27). None of these is announced to the public as recreation places for homosexuals; however their clients go there through information obtained from other customers (mouth-to-ear publicity). In this group of establishments, 2 different types of scenarios were identified: Recreational scenarios that are also scenarios for sexual activities. This is the case of steam rooms and saunas of hotels and recreational centers for families. These are wet rooms that operate in places in which the basic service offered to the public is the bath as a form of recreation. The main actors are men and women older than 15, of middle class or higher, who mainly go there looking for a bath as a relaxing activity. Secondarily, and in a variable degree, they are used by some other clients as probable scenarios for «hooking up». They are announced to the public as recreational places. Their paraphernalia and symbols, both internal and external, allude to sports, exercise, relaxation, and similar activities, as they relate to being healthy and do not make any references to sexual activities. The illumination and special designs in these places do not invite, in general, to intimate contacts among customers. Their tacit rules include the permanent use of a swimsuit, a reserved behavior and the prohibition of exhibiting the genitals, caresses or other expressions that have explicit erotic connotations. One of the critical factors for the success of these scenarios consists on presenting their customers (men, women, and children of different ages) an atmosphere of «non-sexual» public recreation. In general terms, the implicit rule in this scenario is that all that explicitly depicts sexuality is considered unacceptable and awful and it is susceptible to be penalized. The explicit interactions with the intention of genital contact are not well seen by customers and personnel; they generate discomfort and could be punished within the same scenario. MSM go to these places with relative frequency looking to meet another male who accepts a homosexual relationship, one that could pass unnoticed for the rest of the customers. In the described context, the «hook-up» is not a simple process. The «hook up» is based on a specific code that includes body language that is unconscious to the rest of the population, but that can be understood and responded by somebody who is interested in communicating in the same way. MSM interested in «hooking up» should refine their techniques of non-verbal communication to insinuate their erotic interests to the other one: a direct look at his own genitalia or someone else’s or a hand on their own. These signs should appear as an innocent expression in the event that they are perceived by a third party and also that assure that the other one will not feel attacked if he is not interested in the contact. In this way it comes down to a non-verbal communication, intense and silent, which uses a code of signs that are understood only when the other one is sensitive to understand them and to interpret this kind of language. The signs can be manifested in places that favor the intimacy, such as showers or lavatories. If the signs reach their target, a verbal communication occurs in the same place; genital intimate contact usually does not happen in the establishment because the right conditions for intimacy do not exist. If it does take place, it is usually casual and often by chance, i.e. manipulations which happen in hidden places such as toilets. However, the investigators were able to obtain stories about sexual intercourses with penetration and without the use of preservatives. It should be noted that the described «rules of the game» can, at different times of the day, depend on the presence of other actors, as it is the case when family groups are not present in the specific scenario. The low number of customers or staff members also favors the practice of more explicit sexual expressions and furtive contacts. In moments like these, the scenario can be searched for and transformed by customers interested in erotic contacts. Scenarios of sexual activity with the appearance of recreational scenarios. Their basic purpose is to act as scenarios that facilitate both «hooking up» and genital contacts; secondarily, they offer customers steam rooms or saunas and other services for resting and relaxing, which turn into a favorable atmosphere for sexual interactions. These scenarios operate in places without advertisement that identify them as public spaces, and when they do, they advertise these places as public wet rooms. For the unaware client, however, there is not a sign outside that identifies the place as a scenario for sexual activities but, once inside, the scenario can be loaded with symbols that suggest and validate the nature of the place (decoration, erotic pictures and posters, erotic movies of explicit sex on TV circuits). Some advertisement and posters that invite to behave properly («All act against the decency or the morals will be punished») are exhibited to avoid problems with the authorities. Additionally, they generate an ambiguous atmosphere of prohibition as one informant said: «it is forbidden, but at the same time it is allowed and it can be disobeyed without consequences». The distribution of spaces and dimness of the place, favor the intimate contact among customers. Some locations have complementary services, such as reading and relaxation areas, gymnasiums, massage centers, and television rooms where erotic movies are displayed. The owners or administrators of these wet rooms are usually MSM, but also heterosexual males that have found a way to make a profit from this kind of business. In this scenario certain values are considered: physical beauty, age, sexual character, masculinity, elegance and delicacy. The tacit rules of the place allow for nudity and genital contact among the clients. However, interactions with sexual intentions are carried out in accordance with codes that disapprove vulgarity and value delicacy. Although some of the localities offer bar service, the consumption of psychoactive agents and the excess of alcohol consumption are not accepted. The decoration and cleaning of the places vary. One of the places investigated, which we will call «Crystal» (a fictitious name), is preferred by customers because it has special qualities of hygiene, cleanliness, and decoration and it is visited by clients of middle and upper class status, and by foreigners. Its fees are not significantly higher than those of the rest. The hygiene and the quality of service in these places are related to the social status of the clientele. «Crystal» has great popularity among MSM for its exclusivity, service, cleanliness, and refined taste. The aspects related to cleanliness were very important for the study, especially for places from the second group where sexual contacts take place in common areas in which ejaculations drop to the ground, walls, and other objects. This fact can increase the risk for clients to be exposed to secretions infected with HIV or other infectious germs. The maintenance employees must use rubber gloves, but a few of the visited locations systematically use disinfectants to clean the floors. However, this practice seems to have improved since the first study. In this type of public wet rooms, the main actors are the customers, men older than 16 who, for the most part, go searching for sex «…we know very well why we’re there…» Nobody is forced to have genital intercourse, but for everyone it is clear that sex is one of the main attractions of the place and the goal of most of the clients is to have, at least, one genital contact per visit. For eight hours, the costs of the service are equal, on average, to the daily minimum wage for the country (US $7-10) which is high for people of lower class status; thus, customers are usually students or employees of middle class condition, and between 20 and 60 years of age. The customer’s socioeconomic status is related to how much the place charges, but it does not depend exclusively on this factor. In places where the fee is smaller than US $5 the flow of people of lower economic status (workers, high school students, underemployed, and unemployed) is higher. Although the entrance charges seem not to be high, customers become segmented regardless of minimum differences. The customers of «Crystal» are males of middle and high socioeconomic status, intellectuals, artists, professionals, students, university professors, priests and doctors. Therefore, this place becomes something more than a place of random sexual contact, since it allows intellectual and social activities that stimulate the personal development of the actors. Secondarily, it replaces the erotic relationship with another type of interaction and it consolidates a certain sense of ownership over other customers; despite the common interest in sexual interactions and the subjection to the implicit rules of the place, the variability of attitudes and values do not tolerate to speak of a «cultural identity» among the clients. The effeminate or delicate behaviors are tolerated but not shared, and frequently disapproved by several of the MSM that visit these places. Since the attractiveness of these locations depends on the age of the clientele, some places offer special discounts for students. The information and promotion of the place is passed along person-to-person among clients. The days of higher flow are holydays and weekends. Many of the clients remain in the place all day long and during this period they can have several genital contacts with different people. In this type of scenarios MSM can express themselves in a more explicit way because the atmosphere of the place tolerates it and invites them to do so. Customers usually walk nude, only covered with a towel and in sandals; some even walk barefoot. They come looking for another male who accepts a homosexual relationship, which can turn into genital contact in the same place. Just as in the previous scenario, the hook-up takes place through body language directed specifically to the person of interest, although trying to make it unaware to the rest of the public (like a game of insinuation and hiding at the same time). This non-verbal language is, however, more explicit and aggressive than in scenarios from the previous group. For instance, the exhibition of their own genitals and the willingness to touch other people’s genitals or their own can occur. A signal can occur in any room of the scenario, especially in those that promote intimacy, such as showers, lavatories, and dark places. In spite of the permissiveness of the place, the verbal and explicit expressions of sex are not welcomed by the players, who prefer the delicacy of the expression and the charm of a more elaborated hook-up. If the sign reaches its objective, a genital contact can occur, which is carried out in the same location. It is often a rule of this scenario that each one of the clients has the right to participate or to refuse sexual contacts and, consequently, these ones do not involve any commercial transaction. Despite the above-mentioned fact, those who refuse to establish sexual contacts can be considered by other customers as «snobbish» (arrogant or conceited) because it is assumed that those who go to the place know what to expect. Some places offer private rooms to clients equipped with mattresses «for resting» (relaxing rooms), which the clients usually use for sexual encounters. The gay wet rooms of the area usually distribute condoms to their clients. However, it is frequently that customers practice unsafe sex instead. According to some stories, the use of condoms by customers has decreased during the last years. Under the described conditions, ejaculations are dropped on the ground. Genital contacts are possible in this scenario because there is an unstated rule which allows them and invites to do them in certain intimate places within the location. However, they can take place before other clients’ presence. Some of them usually stimulate themselves by looking at others and they come motivated by this practice. According to the interviewees’ opinion, group sex practices among customers, which were reduced at the end of the 1990s due to AIDS fear, has increased again since the effectiveness of antiretroviral treatments has been recognized, because now AIDS is not perceived as an immediate cause of death; available treatments generate a sense of safety and this confidence affects each customer’s decision to protect themselves or not. In spite of the permissiveness of the scenario, there are implicit rules that must be observed: sexual contacts should be free of charge and volunteer and nobody may be forced to perform them; explicit sexual activities are allowed, but offensive exhibitionism is considered unpleasant; the use of psychoactive drugs is not well seen, and, when staff members are nearby, genital contacts are not allowed in the Jacuzzi. These regulations are not communicated neither in a verbal nor in a graphic way, but through the clients’ attitude of disapproval, indifference, isolation, and avoidance towards the perpetrator. A customer can establish several different types of contact and with several different people in a single visit to the place. Younger or more handsome customers have a higher probability of intercourses and can select and get into contact with other clients, «…but nobody misses the chance…». In this context, youth and physical appearance constitute, according to the testimony of the players, one of the most important factors at the moment of selecting or being selected for a sexual relationship. A client can refuse a request from another one if he does not find him attractive; the sign of rejection are usually non-verbal expressions such as a deviate look, the retreat of the hand or the absence. Genital contacts are usually anonymous. Verbal communication and mutual identification, if they occur, usually take place after the genital contact, as a complement. Although inside the scenario the physical contact between two people can be very intimate, it does not involves necessarily other types of relationships and the communication usually finishes after the genital contact has been performed or after leaving the place; the link that is created around the sexual intimate contact is usually very weak. Unless both have achieved a certain level of understanding, each one will take his own way after the act looking for a new contact («... and if I see you I don’t know you»). Sexual activities are not the only motivation offered by this scenario. A good number of customers usually dedicate great part of their time to enjoy baths or watch television in which movies of explicit sex are exhibited. These exhibitions act as an erotic stimulant, they motivate and validate different kinds of sexual contacts (still without condoms) and they are part of what is valued and accepted by clients. The egodistonic homosexuality, in which the individual finds it difficult to accept himself and causes discomfort within his familiar and social groups, can be relatively frequent among customers and the unpleasant feelings are more common when entering or leaving the place than when being inside, where the suffering is compensated by the anonymity and the rules of the house. The legitimacy of sexual activities within the scenario makes the stimulating effects of alcohol and drugs lose importance in front of other motivations generated by the distribution of the space, the lights and the paraphernalia. Due to the above-mentioned fact, most of the sexual activities that take place in these scenarios are carried out in a relatively conscious and voluntary way, as product of a decision which cannot be attributed to the alienating effect of psychoactive drugs. The autonomy of the actors to assume protection measures is, however, very limited; stimulated from different ways by the atmosphere of the scenario and the rest of the audience, customers can be wrapped in compromising situations, which are difficult to approach rationally, and not always with a condom at hand… «Sooner or later the moment arrives in which it is impossible to go back…», «a rigid dick (erected penis) does not believe in God» said a speaker as a way to express that, once the excitation appears, it is difficult to avoid the intercourse even under unsafe conditions. Other factors influence these decisions: still in these scenarios, which stimulate and legitimate homoerotism, achieving a conquest can be difficult and the risk of losing the opportunity of a contact becomes stronger than the risk of acquiring a STD; this difficulty could be more important for less attractive or older customers. However, younger or more attractive clients could have a higher rate of partner replacement and, for the same reason, a higher risk of acquiring or transmitting a STD. 3. Parks. Due to the fact that parks are public spaces, practically all of them are also potential places to «hook up» for different groups of people at different hours of the day, especially at night and dawn. About MSM, the study identified Parque de Bolívar, a central place in the business district of the city, as an important scenario for a special type of sexual conquest endorsed by money, which acts as another form of commercial activity. In this scenario, which could be approached from the perspectives of marketing studies, there are two kinds of actors: the sex sellers and their clients. Most of the sex sellers are teenagers of low and medium socioeconomic class who need money to survive, buy clothes, use drugs or waste in electronic games. According to some stories «…The boys at parque de Bolívar are going through competition and devaluation processes inside the market that make them devaluate…». Their offer is permanent at any hour of the day. However, the sexual trade activity is higher after 6 PM and on Fridays and Saturdays. Teenagers stroll alone around the park or near the road, in front of some of the commercial places of the area (i.e. XXX theaters) waiting for a potential client they could insinuate to with signs that they are interested in the deal: a fixed look to the eye, a hand on their own genitals, a request for cigarette or currency for a telephone call. This industry has been technified; now there are middlemen who approach the potential clients and offer them a teenager for a commission; the middlemen are hatred by teenagers who consider them as exploiters. The young sexual workers at Parque de Bolívar maintain sexual relationships with people of both sexes, but they do not consider themselves homosexuals. The gathered stories suggest that «The economic and affective conditions help a lot (to understand their situation)». Several of the boys from the park do not admit what they do, but do not look for a way to escape. In their opinion they would want an opportunity to get out but they consider that doors are closed for their personal development. Most of these boys do not belong to a formal labor market and many of them consume psychoactive drugs during this activity, what facilitates their engagement into high risk practices. The customers for this scenario are mostly middle and upper class bisexual males older than 30. Frequently they come to the park and then drive around until they make the contact. Their preferences point towards good looking teenagers with virile aspect («...very machos»). The deal is usually settled down inside the vehicle. Rates do not exist; the sexual workers usually charge a «liga» (tip), appealing to the client’s generosity. This value is very variable and it usually fluctuates among US $10 and US $20. However, a session of oral sex can be carried out for US $5 or US $6. Younger and handsome boys usually charge more. The sexual contact does not take place in the same park, but inside the vehicle or in motels. In the sexual workers’ opinion: «this business is getting harder, because a lot of people are entering to it». In this respect, the study found a conflict of interests that often produces physical aggressions, among three groups that compete for the sexual market of the area: the female sexual workers, the young male sexual workers, and the transvestites. Despite of their vicinity, Parque Berrío is a very different scenario, preferred by the «old folks», that is to say, by older and more experienced men. The importance of this scenario for «hooking up» is smaller than Parque de Bolivar’s. The sex sellers are usually bisexual young men who need money, according to their words, «to use drugs or to maintain their girlfriends». The clients are mature men of lower and middle economic class. The prices are smaller and «the business there is worse because clients are harder.» At parks, the actors are submerged in a system of relationships which influence their risk management and limit their autonomy to assume protection measures. In such a competitive business, the young sexual workers have difficulties to choose their clients or to impose them their requirements to use condoms. On the other hand, most of the clients who come to these scenarios look for brief and anonymous contacts which frequently do not lead to protection measures. 4. Cycle-roads. In certain days of the week, the public roads, dedicated to the practice of sports, become recreational and «hooking up» scenarios for MSM. The scenario is built around key elements that induce the conquest attitude: the age of the assistants, the sweat suits that allow exhibition and observation of areas of the body usually covered by more formal clothes, the anonymity, and the availability of free time for recreation. People go to these places to entertain themselves, so they generate a system of rules which reject explicit sexual expressions, especially if they have homosexual components; paradoxically, this scenario accepts and reinforces another type of message that is related to gestures which suggest an open-mind about sex. In this context the MSM «hook up» appeals to especially subtle expressions, favored by the signs of the receiver, which should be brief and hidden for the rest of the public. The cycle-road activity is an ambivalent scenario towards sexuality, and in this context MSM should communicate by means of non-verbal codes open to actors that, in turn, have a receptive attitude. 5. Malls. Places of electronic games, halls and rest rooms of big malls and commercial centers were also identified as scenarios to conquest and even for genital contact among MSM, especially among teenagers and young males of middle and upper social classes. Older males go to electronic games hoping to get the attention of the younger ones. The information obtained in relation to this topic was not enough to facilitate the comprehension of this scenario. 6. Cinemas. Some XXX theaters of the area have become MSM scenarios for hooking up and genital contact. The scenario is built around the darkness, the tranquility that offers the anonymity, and the complicity that generate the movie as a collective erotic stimulus. Most of the clients go alone. Hooking up is carried out through a non-verbal and corporal language. People who go with this objective stroll by the room or locate themselves next to entrance doors or near lavatories. «One detects them easily... because they walk and walk as looking for something» said one of the interviewees. Different genital contacts are carried out in the projection room or in the lavatories. Condoms are not usually used. Homosexual contacts prevail, but it can also happen among heterosexual couples. The scenario, conformed also by heterosexual and bisexual clients, is permissive with this type of behavior that is usually carried out with the help of the darkness. Most of the porn cinemas of the metropolitan area are located in areas frequented by people from lower economic classes; the clients are also predominantly males of all ages, heterosexual and homosexual, of low and middle socioeconomic classes. In some of the establishments they also consume psychoactive drugs (marijuana and pasta of coca). The situation is known by the administrations of the movies, who, according to the stories, act as if they do not know. 7. Internet booths. This scenario was not found in 1993 and it has expanded notably from 2000. The Internet booths are concentrated in the downtown area; some work 24 hours a day and usually have cubicles with closing doors, which generates an intimate space where customers consult erotic material for adults on Internet. Some of these places are usually visited by clients that leave the bars between 1:00 and 2:00 am, when those places close their doors. The booth does not have a restriction to be used for more than one person. The exchange of visitors in the cabin and the contacts of erotic type among customers are accepted tacitly for both the administrators and the costumers. Several of these Internet places they were «taken» by MSM with the indulgence of their proprietors that see this transformation of the scenario as an economic opportunity. 8. The streets as hooking up scenarios. MSM have built in the streets two types of scenarios for hooking up: a. Streets of hooking up for money: sexual contacts are carried out for money by teenagers and young boys of low and middle economic classes that remain there strategically offering their services as sexual workers. It is likely that thieves post as sexual workers to contact their clients and rob them. b. Hooking up streets where the conquest is usually achieved to give pleasure to people in the vicinity of commercial centers during the day or in certain traffic roads during dawn and after the rumbas. This scenario is frequented by young homosexual and bisexual males of middle social class. The contacts settle down by corporal language and mutual agreement and not for money. Some areas of the city, because of their isolation characteristics (the freeway and roads near La Macarena) were, not long ago, places not only for hooking up, but also for sexual activities. Although, their isolation also implied the risk of assault or abuse by the police. «In that time one had to go to those places in spite of the danger … Now at least we can go to the saunas, with more tranquility» the interviewees affirmed. In the vicinity of bars, parks, and some roads it has also increased the participation of children who offer their sexual services to wealthy men that visit the encounter places. A frequent modality is the exchange of sexual favors for benefits highly valued by children and teenagers, such as clothes and expensive accessories or cash. Several of these teenagers carry out the transaction for objects or money with the intention of improving their physical appearance, which is highly valued by them. Frequently, these teenagers maintain sexual relationships with their girlfriends at the same time. To this respect, the speakers consider that bisexual behavior have increased among teenagers. DISCUSSION In connection with MSM, the current characterization of scenarios and actors continues to be similar to the one observed in the 1990s. The main variations refer to the increasing number of actors who go to the scenarios and the proliferation of places dedicated to this business. These changes could be understood better from the market perspective, which has discovered in MSM a discriminated against group, but one that is able to behave as a consumer and, consequently, a generator of utilities (4). MSM has become the central object of a business that its owners perceive as a market in development. Service offers have been broaden and refined because of the demand and consumption capacity this group generate. This process, which began in the urban center of the capital and has extended progressively to other municipalities within the metropolitan area, has been also described in other regions of Latin America (28). Exposed to exclusion processes and discrimination that do not allow them to appeal to the same interaction mechanisms allowed to the heterosexual population, MSM have a smaller autonomy about their sexuality, and they are forced to build parallel scenarios for conquest, sexual activities, and personal development. These scenarios are conformed by implicit systems of rules that the participants adopt as values and that the market understands as goods. The values shared by the group in these scenarios constitute an implicit code of ethics that is imposed over the decisions of the actors and whose adoption allow MSM to carry out some of their fundamental needs, but it reduces, at the same time, the control margin about their risks and safety. The ambivalent effect of the scenarios was one of the most outstanding discoveries in this study. According to the stories obtained, MSM consider that the described scenarios are an important resource that contributes to their personal development and solve several of their needs of identity, recreation, affection, freedom, and communication. On the other hand, the scenarios admit and reinforce behaviors that increase the risk of acquiring HIV or another STD. In these scenarios, the risk of losing an opportunity of genital contact is perceived as «more valuable and true» than the risk of infection, and this valuation plays a crucial role at the moment to make a decision of protection. Transformed into «rules of the house», not protected sexual activities are cleaned of their potential danger, therefore assuming elements of «normality» and safety. As such, they are not perceived as dangerous nor they generate in the person the necessity to develop a special behavior of self-protection. The rules of the scenario limit the margin of the actors’ sovereignty on the individual decisions related with their protection and their risks management and suggest a more complex and structural vulnerability. In spite of the above-mentioned fact, not all the players act in the same way inside the scenario, and this discovery suggests the role of another type of personal conditions (personal vulnerability). It could be that, in these scenarios, MSM accepts the rules of the house because they understand and perceive them as reasonable, desirable, and apropriate (29) in an environment that favors their adherence (30). However, the study did not reach deep into this aspect. The convergence of structural and personal vulnerability conditions reveal the necessity to take these preventive programs beyond the information for the individual self efficacy (28,31-34). The possibility of genital contacts is one of the biggest attractions in the described scenarios. Paradoxically, the same actors that recognize the value of sporadic sexual contacts claim for the lack of a stable partner and they reject «the infidelity» of their couples. This argument, seemingly contradictory, was found in an iterative way along the study and it reinforces the idea that the described scenarios have arisen and they stand, at least partly, as reaction to the stigmatization and the discrimination that prevent the MSM from establishing long-lasting relationships with others. In spite of the expansion of the described scenarios, and that in the last years it has been observed in Colombia a higher social tolerance in front of the sexual diversity, the study suggests that, in this region, stigmatization continues to be a mechanism of social punishment in front of MSM, and that this condition influences their conception of the world and their behavior patterns related to the risk of infection for HIV (27). The MSM scenarios for conquest, contact, and personal development are a segment in expansion inside the sex market. A market with a strong development that constitutes an important source of wealth for their proprietors, although still characterized by secrecy. This market is not, like it could be thought, a scenario of multiple opportunities where each actor is competent to assume his protection measures. Although the population of MSM enjoys a wider variety of possibilities for their erotic or social encounters, their autonomy and capacity to assume protection measures are circumscribed to the conditions defined by the administrators of the business. Risks management is given then within the context of the markets and the possibilities (conditions) imposed by the offer (the rules of the house). Despite the fact that in recent years a bigger concern is observed by the administrators of these places in connection to HIV prevention, they are not totally independent to take preventive measures in a society where these businesses are in the verge of illegality. Some of them are really worried about HIV and they place preservatives to the clients’ disposition, but they cannot do it explicitly since this would serve as a recognition that in their facilities there are illegal sexual practices and they could have problems with the authorities. To this respect, the actors were repetitive in the defense of scenarios like saunas, taverns, and clubs, because they consider that these places offer them better personal security, not only from the transmission of HIV but also from the aggression of a third party. Their segregation and insecurity feelings could get worse if these places would have to close. The information given by the actors also suggests that the population of teenagers and young males involved in the sexual trade with MSM has risen. Little is known in this region about this and the results of this investigation raise a wide question about the emphasis that these campaigns should have to prevent the transmission of HIV among teenagers. CONCLUSION In this region, the homosexuality continues to be the object of social punishment and sexual rights of MSM face multiple difficulties and risks. Under these conditions MSM should take the advantage to create special scenarios where they can enjoy their sexuality without difficulties from the outside. Similar to what has happened in other countries, the interests of the market here have favored not only the expansion of these scenarios, but also the social mind towards the homosexuality. This process could be possibly reinforced in the next few years and is especially important to establish the contents, the feasibility, and the potential effectiveness of public health policies directed to intervene in this epidemic. In the described scenarios the inventory of sexual behaviors of MSM varies in connection to imposed implicit rules that are induced by the rest of the public and legitimated by the offer. This behavior patterns (rules of the scenario) represent for the actors the possibility to develop their personality, thus avoiding the social sentence and the pointing, and, at the same time, these patterns expose some of them to a higher risk to get and or transmit a STD. Nor the men caught by the steam room’s erotic atmosphere, nor the adolescents that stroll in the park or the vicinity of the «hot spot» (zona rosa) to exchange goods for sex, nor the half-drunk workers who rush their way to the tavern, are used to the definition of the classic American man who is rational, aware of the risks he makes, concerned about his own personal security and free to decide… here they behave as actors that improvise their scripts as a response to external conditions that are directed by the public. When they develop their role, some actors have a wider repertoire of answers and a better capacity to invent. However, what is expected is that most of them assume their role and adjust their manners to the rules of the house. These findings illustrate the complexity of subjective decisions implicated with personal protection and administration of the risks, and they question the paradigm of rational consumers. On the contrary, the confluence of structural vulnerability and the individual vulnerability in a context of social exclusion make a complex net of economic and social determinants of the risk that should be assumed in their complexity and integrity by health policies. REFERENCES
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