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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.24 no.12 Rio de Janeiro Dec. 2019  Epub Nov 25, 2019

https://doi.org/10.1590/1413-812320182412.27842017 

FREE THEMES

Male sex workers: between safe sex and risk. Ethnography in a gay sauna in Barcelona, Spain

1Servicio de Epidemiología, Agència de Salut Pública de Barcelona. Plaza Lesseps 1. 08023 Barcelona España. cjacques18@yahoo.es

2Universitat Rovira i Virgili (URV), Tarragona, España.


Abstract

This ethnography was conducted in Barcelona, a city that provides different gay leisure resources, such as gay saunas. We aimed to analyze from studies on gender and masculinities, how sexuality, perception of HIV infection and other sexually transmitted infections (STIs), and preventive measures are articulated in gay sauna male sex workers (MSW). Ten in-depth interviews and observation were conducted between 2012 and 2016. Safe sex practices are more frequent with clients, while risk practices are carried out more with non-commercial partners. Sexual orientation plays an important role. Homosexuals assume riskier practices in sex work than heterosexuals. Drug use or lack of support networks were associated with higher social vulnerability and risk behaviors. Contracting HIV still creates fear, while having other STIs is perceived as part of a man’s sexual life. The MSW affirms masculinity with concurrent sexual partners, breadwinner, and on the other hand, questions a heteronormative model. Interventions for the prevention of HIV and STIs in this group should consider social determinants such as inferior work alternatives and the provision of more significant social support.

Key words Sex work; Masculinity; HIV; Ethnography; Sauna

Resumen

Esta etnografía se realizó en Barcelona, ciudad que ofrece diferentes recursos de ocio homosexual, como las saunas gay. El objetivo fue analizar desde los estudios sobre género y masculinidades, cómo se articula la sexualidad, la percepción sobre la infección por VIH y otras infecciones de transmisión sexual (ITS), y las medidas preventivas en trabajadores sexuales masculinos (TSM) usuarios de saunas gay. Se realizaron 10 entrevistas en profundidad y observación entre 2012 y 2016. Las prácticas de sexo seguro son más frecuentes con clientes, mientras que las de riesgo se realizan más con parejas no comerciales. La orientación sexual juega un rol relevante, los homosexuales asumen más prácticas de riesgo en el trabajo sexual que los heterosexuales. Consumo de drogas o la escasez de redes de apoyo se relacionaron con mayor vulnerabilidad social y conductas de riesgo. Contraer el VIH aún genera miedo, mientras que tener otras ITS se percibe como parte de la vida sexual de un hombre. El TSM afianza una masculinidad con múltiples parejas sexuales, breadwinner y por otra parte, cuestiona un modelo heteronormativo. Las intervenciones para la prevención del VIH e ITS en este colectivo, deberían considerar los determinantes sociales como las precarias alternativas laborales y el ofrecer mayor soporte social.

Palabras claves Trabajo sexual; Masculinidad; VIH; Etnografía; Sauna

Introduction

Male sex workers (MSW) defined as men who sell or exchange sex for money or goods are a very diverse population among different countries, and even within the same country1. Although MSWs offer sexual services to men and women, male clients are much more frequent2. Besides the risk involved in the practice of anal sex, several social determinants such as having limited economic opportunities, the lack of legislation and protective policies in matters of sex work (SW) and the invisible nature of this activity place MSWs in a position of vulnerability to contracting HIV and other sexually transmitted infections (STIs)3.

At the Spanish level, the self-reported prevalence of HIV was 17.5%4 in a sample of 487 men who declared having sex in exchange for money. In Barcelona, of 548 MSWs presumably seronegative to HIV or with unknown serology and submitted to a rapid test in gay saunas, 8.7% were reactive to this test5. However, studies on male sex trade are scarce since research on HIV and other STIs usually include it in the category of men who have sex with other men (MSM) or within the group of people engaged in prostitution, which include women and transgender, groups with very different characteristics1.

Prostitution is alegal in Spain; it is not regularized or penalized, what is condemned is pimping, the fact of forcing someone into prostitution and obtaining benefits from it. The press and the media set Spain as one of the leading destinations for those seeking paid sex6. Barcelona provides resources for leisure and consumption of paid sex aimed at the homosexual public, as well as places to have sexual relationssuch as gay saunas7. These places favor anonymous encounters for men to interact socially and sexually and are perceived as permissive and at risk of contracting HIV by the very users of these places8,9.

Gender studies show how sociocultural patterns, social and sexual practices are modeling masculinities and influencing health10. The literature on this subject has focused mainly on the hegemonic model related to assuming risk behaviors, not showing weakness, and exhibiting a high degree of virility11. They also point out that men are less willing to consult health professionals and express their fears despite worrying about their health, an exacerbated situation in less favored social classes and stigmatized diseases such as HIV/AIDS12-14.

In this regard, ethnographic research is recommended in order to understand better the incidence, contexts, and risk behaviors associated with sexual relationsbetween men and transmission to their sexual partners15. This study focused on indoor prostitution in a gay sauna, and aimed to analyze, from the perspective of masculinities, how sexuality is articulated, the perception of HIV infection and other STIs, and the preventive measures of MSWs that offer their services in gay saunas in Barcelona.

Methods

This research was developed from the socio-constructionist perspective, which proposes that people’s experience and statements are the product of social and historical processes. An exploratory and ethnographic study was conducted between 2012 and 2016 in a gay sauna in Barcelona, and 10 in-depth interviews with MSWs were held in 2015 and 2016. Observations were made in the sauna, and field notes were taken. In the sauna, the research team, consisting of a psychologist and anthropologist, two nurses and a doctor, participated in informal interactions with sex workers, clients, and employees of the establishment.

This study was carried out within the framework of the “Saunas Program” carried out by the Public Health Agency of Barcelona (ASPB), which consists of providing rapid tests for HIV, other STIs, and vaccination against hepatitis A and B in different gay saunas. Users collect the test results at the ASPB, where they receive counseling, and HIV positive cases are referred to hospital units for confirmation and treatment. The sauna was selected by convenience since it is one of the places where SW is exercised.

Semi-structured interviews were conducted, sociodemographic information was collected, and six topics on the experiences and beliefs of the MSWs were explored through a script (Chart 1). The interviews were recorded, except one, since the MSW wanted to keep his full anonymity. Once interviews were transcribed and field notes compiled, an interpretative thematic analysis was carried out to identify underlying ideas, assumptions, and conceptualizations from which categories and subcategories were established16. The analysis was flexible and conducted throughout the fieldwork by researchers who participated in the observation and interviews, and was triangulated by experts in Public Health and Medical Anthropology. This study was approved by the ethical committee of the Hospital del Mar de Barcelona and with the informed consent of the respondents. Those who agreed to participate received a 10-trip urban transport card worth 10 euros as compensation.

Chart 1 Script of the semi-structured interview conducted with male workers in gay saunas. Barcelona, 2015-2016. 

Topics to explore
Reasons for having started sex work
Experiences associated with the exercise of sex work in the sauna, with clients and partners
Socialization of sexuality and attitude towards homosexuality
Experiences and representations about sexual practices by commercial and non-commercial sexual partners
Representations of HIV and other sexually transmitted infections
Perceived and proposed needs for the prevention of HIV and other sexually transmitted infections in MSW

Contact with participants

The interviews were provided to the MSWs contacted in saunas and those who came to collect the result after the tests were carried out. All interviews were conducted at the ASPB in order to preserve confidentiality and privacy. Of the twelve MSWs that were offered to participate, two refused, claiming that they did not want to talk about their sexual relationships with other men and both self-defined as heterosexual. Finally, ten MSWs from different countries were interviewed, four self-defined as heterosexuals, five as homosexuals and one bisexual. The possibility of adding some information was always left open, which allowed three of the informants to be interviewed more than once. The characteristics of the respondents are described in Chart 2. The study was closed when data saturation was reached.

Chart 2 Sociodemographic characteristics of the 10 male workers interviewed. Barcelona, 2015-2016. 

Id Age Country of birth (year of arrival) Schooling Marital status Self-reported sexual orientation Places/strategy to contact clients Sex work start year HIV serological status Regular status3 TSI4
1 26 Panama (2011) Primary School Married to a woman Heterosexual Sauna 2014 Negative Yes Yes
2 21 Brazil (2015) Secondary School Single Homosexual Sauna / advertisements1 2015 Negative No No
3 29 Romania (2007) Illiterate Single Heterosexual Sauna / nightclubs 2011 Negative Yes Yes
4 26 Romania (2009) Secondary School (Incomplete Higher Education) With female partner Heterosexual Sauna 2010 Negative Yes Yes
5 37 Brazil (2003) Secondary School (Incomplete Higher Education) Single Homosexual Sauna / advertisements 2000 Positive Yes Yes
6 26 Brazil (2014) Secondary School With male partner Homosexual Sauna / advertisements 2014 Negative No Yes
7 29 Spain Secondary School Single Homosexual Sauna /nightclubs 2004 Negative Yes Yes
8 30 Brazil (2006) Primary School Single (follamiga = friends with benefits)2 Heterosexual Sauna / advertisements 2006 Negative No No
9 26 Venezuela (2003) Secondary School (Incomplete Higher Education) With male partner Homosexual Sauna / advertisements 2014 Negative No Yes
10 34 Senegal (2007) Primary School Single Bisexual Sauna 2009 Negative No Yes

1Advertisements: Offer of paid sex through the announcement on the app or Internet for sexual contacts.

2Follamiga (Friendship with benefits): couple relationship that combines friendship and the possibility of having sex, without committing as a sChart partner.

3Regular status: having a residence or nationality that allows one to live in the European Union in an administratively legal way.

4TSI: Individual Health Card, the document that allows access to the benefits of the Spanish public health system.

Results

Six thematic categories were established: sex work in gay saunas; sex work: benefits and disadvantages; dynamics and social relationships in the sauna; sex work as a man; sexual practices by type of partner and HIV/STI/prevention. Chart 3 shows a selection of textual quotes from the interviews.

Chart 3 Textual quotes of the interviews made to the informants. Barcelona, 2015-2016. 

Topics Verbatim
Sex work in a gay sauna "That is why I left there (from the apartment) ... once the client went to pay me... and I discovered that they paid € 150 an hour and... the owner paid me € 40 per hour, and when I discovered what the owner was charging, I saw that it was not fair" (Id6)
"I do a ritual of spiritual, emotional, and physical cleansing. I wake up, I pray, and I engage in physical activity, and in the end, I go to work and enter hell, that's what we, who do not like women, call the sauna." (Id8)
Sex work: benefits and disadvantages ""I stayed four years in jail... I had been there several times (for theft), I am very grateful to be living in Spain and for the opportunity to have a more honest job that generates money for me, such as prostitution" (Id3).
"You can earn money if you are clever. I have bought two apartments over two years" (Id6)
"People need the drug to stay awake, to fuck with people" (Id9)
"(With the tub) What I noticed sexually is that I began to have thoughts that seemed like they were not mine: from dirty talking or fetishes, you dare to do certain things that you would not do regularly, you break barriers." (Id 5)
Dynamics and social relationships in the sauna "The client likes me, and he is not any client. He knows that there is a price and a special place for them... he will want a drug-and-sex party and have a good time..." (Id1)
"Poop, piss, vomiting... Complicated people, which I think are a little retarded. You can end up crazy if you are not mentally strong." (Id8)
"They like to pay because they get the idea that this is a product that it is a boy who is rented for specific practice and the customer likes that kind of idea or vice or morbidity..." (Id9)
"Many clients make you feel good, they treat you very well, and you feel loved and accepted..." (Id7)
Sex work as a man "... I don't like to call myself a prostitute, nor do I like to be called hustler, because we are all promiscuous; men, in general, are promiscuous; they are promiscuous by nature" (Id 9)
"I started very early, with my cousins, with the female housekeeper who worked in my house. Nothing homosexual, I learned through experience. In Brazil, things are clear. I saw my aunt from my room, fucking ... I was 7 or 8 years old. Then I saw another aunt..." (Id 8)
"Most gays are very vicious and use many drugs, and don't think much about the risks." (Id2)
"... Normally they look for very unclean guys, very slender bodies, curved bodies: the fat ones would not enter there... for work no, as clients yes." (Id9)
"What is it to be a man? Be clear and make things clear. I seek life here" (Id1)
Sexual practices by type of couple "With customers, it is colder than with the boy I am with. No kisses, always with a condom ..., sometimes, I don't use a condom with non-commercial partners." (Id2)
"Me and most of the guys use prevention with customers, but not with their partners." (Id5)
"With women, I use it (the condom) at first, but then not; why? Because I always trust... the clients... with women, I ask for the tests [and if they don't do it?] then I'm going to do them..." (Id3)
"Gays are more likely to catch a disease because they like what they do. As if I had to work with women." (Id8)
HIV / STI /
Prevention
"Doing it without a condom ... gonorrhea, things like that ... because I have touched that girl you know and after a month you get these things... I get angry because I have not taken care of myself, and it could have been worse" (Id1)
"(HIV) That you can die, there are medications but I am very afraid" (Id2)
"I had some of these, syphilis, perhaps... I went to the pharmacy, they gave me an antibiotic and it disappeared" (Id7)
"Those who want everything... if a client asks you if you fuck without a condom, for me he is already showing that he has AIDS. If he sucks your semen... and you don't know that person, it means that he does it with everyone and is not healthy." (Id8)
"There's nothing you can do. It's all the same to them, they like what's behind ... boys are informed but don't want to take care of themselves." (Id 3)

Sex work in gay saunas

The sauna is open 24 hours a day, and is equipped with swimming pools and offers spa services, as well as a bar and rooms freely available, and other more private rooms through extra payment. The user who enters receives a towel, pool sandals, a condom, and locker keys. This establishment does not obtain any direct economic benefit from the SW. What happens inside is a transaction that managers say is not their responsibility. The sauna exercises the right of admission, as commented by some MSWs: entrance is restricted, either through beauty criteria or for having caused some trouble before.

Among the benefits of working in the sauna, as opposed to offering sexual services in an apartment, the possibility of choosing the client, freely managing time and having greater economic autonomy was noted since the gain of transactional sex is an exclusive benefit of the MSW. Sauna MSWs are, in general, young gym-shaped and well-built bodies. Some MSWs spent the night in the sauna, especially those who worked seasonally in different Spanish or European cities, thus saving the rent of a room or house while residing in Barcelona.

MSWs referred to the sauna as “the office”, as a way to normalize the place and their professional activity. However, in one of the interviews, a self-defined heterosexual MSW called the sauna “hell”, since it was a place that questioned his sexual desire.

Sex work: benefits and disadvantages

The reasons for engaging in SW are diverse. In most cases, one enters through a friend or acquaintance. On the one hand, there were talks about the economic need related to emergencies experienced as extreme, such as paying rent or paying for the mother’s surgery in a foreign country. In other cases, it was out of curiosity, in men who felt homoerotic desires but lived in homophobic environments where it was hard to relate to other men.

Immigrant men in an irregular administrative situation were faced with very reduced and scarce employment opportunities, especially during the socio-economic crisis. Although there were some Spanish MSWs, most were from Latin American countries and Eastern Europe. The difficulty of entering the formal labor market was not only related to not having a work permit, and in some cases, to the low educational level but also having experienced structural racism. On the other hand, the most accessible labor alternatives for some MSWs crossed the threshold of legality, with which the SW became a good alternative.

One of the worst problems perceived by the MSWs was drugs. Drug consumption occurred at the customer’s request and to withstand long work hours. Indeed, some respondents commented that they started to consume in the sauna. The use of sexual stimulants was also widespread. Some MSWs also used drugs outside the workplace, at leisure or in other saunas. In some cases, they participated in chemsex a session, which involves the consumption of some drugs for sexual purposes for several days.

On the other hand, one could observe that, for some, the experience of having sex with men was lived with conflict, especially for heterosexuals or for those who had greater internalized homophobia. Another disadvantage mentioned was the lack of legal support regarding their rights as SW. Besides the risk of contracting diseases, they pointed out loneliness and that few people in the family or social environment knew what they were doing.

The economic benefits prevailed among the SW benefits. Depending on the days and the time of service with a client, one could earn up to 8,000 euros per month. The savings allowed buying homes in the country of origin, investing in training courses and sending money to their countries of origin to help support the family, as well as acquiring new cutting-edge devices (mobile phones, headphones, among others).

Dynamics and social relationships in the sauna

In general, the relationship with customers was appreciable. Problems emerged when someone did not want to pay what was agreed. Usually, the services that were requested were massages and sexual intercourse, but some practices could stress MSWs when clients requested MSWs to defecate or vomit on them. On the other hand, the demands did not always respond to sexual fantasies, since sometimes clients only wanted to share drug use or talk. The sauna was considered a good place to contact customers who later became fixed clients and with whom they could have relationships for years. Indeed, it could be the case that the client became a supportive relationship, not only economic but also emotional.

In an interview with a client, a retired doctor, he commented that the boys (MSW) held power in the relationship since an older man cannot have sex with a young and attractive man if it is not through payment. However, this was not the MSWs’ perception, which competed to attract the customer that could generate more significant benefits; in that way, the money became a demonstration of the client’s power in the relationship with the MSW.

Concerning the relationship with the MSW partners, we could observe how social relationships were established between those from the same country or “friendly countries”. It was also commented that they competed with each other, and sometimes some prejudice and racist attitudes emerged among the different groups, giving certain groups less social status. For example, Brazilians commented that they were the oldest in the sauna and those that generated the least problems. The few Hungarians there considered they had better education and economic status than the Romanians.

Sex work as a man

Few MSWs expressed shame or guilt for performing SW. Those who did were heterosexuals since money was considered a good source of compensation. Some did not feel identified as sex workers, but rather SW was understood as an activity that prolonged what is typical of men: having many and varied sexual intercourses.

Regarding the development of sexuality, what was commented is that the social, and not the institutional environment was the source of sexual education. For example, observing sexual experiences during childhood or living in environments where social relationships were mediated by strong erotic content, especially in MSWs from Latin American countries. In one case, sexual abuse was reported at puberty. The respondent hinted that it was the reason he had sex with men.

The MSWs that agreed to participate in the interviews indicated that they had no prejudice towards homosexuality, although their culture of origin (religion, family, and the like) stigmatized it. Instead, we could see how some MSWs showed rough masculinity and claimed that they only liked women, denying their sexual desires towards men.

The typical characteristics of men included honesty, fulfillment of certain obligations, being good people, and having a good job. Statements that pointed to man as an irrational being who only seeks sex also emerged. Although men were referred to as equals, the interviews evidenced gaps between homosexuals and heterosexuals, although some doubted that there were heterosexual men in the sauna. It was commented that homosexuals fell in love more easily, were more sensitive and more vicious than heterosexuals, which led to greater risk-taking. The fact of having a stable partner led the MSWs to adopt more preventive measures for fear of infecting him.

MSWs stated that clients are looking for men with traditionally manly traits, male models that respond to beauty criteria related to strength and youth. However, one MSW said that masculinity was not there to show certain patterns but to assume specific values.

Sexual practices by type of partner

In general, the MSWs associated the risky sexual practices with the fact of not using the condom in anal or vaginal sex, although they also related it with kisses, putting the fingers in the anus or with anal penetration without ejaculation. Sexual practices and prevention measures were different with non-commercial sexual partners and clients.

Condom use was more frequent in paid sex, while with non-commercial couples, where relationships sought pleasure, there was less condom use, especially after some time of relationship. That is, there was a higher perception of risk towards customers than with non-commercial partners. However, on one occasion, for a large sum of money associated with a perception of trust, one of the MSWs did not use the condom with a fixed client and became infected with HIV.

MSWs believed that homosexuals were more exposed to STIs since their sexual relations was mediated by pleasure, not only in the context of occasional partners but also among the MSWs partners, when, for example, a client requested to perform group sex. In the case of heterosexual MSWs, pleasure was also related to lower levels of prevention measures, but with women. Some of them believed that the only preventive measure was to be tested for HIV periodically. Another essential element was the need to feel sexually desired where situations of loneliness, lack of supportive social networks, and search for affection were factors that increase the vulnerability to participate in risky sexual encounters.

HIV/STI/Prevention

The perception of HIV infection and STIs is different. In the case of HIV, social stigma and fear persist, and in some cases, it was related to a death sentence, which led to some MSWs not wanting to be tested. Some statements also expressed serophobia; that is, they refused to have sex with people with HIV. There was a perception that people with HIV engaged in riskier sexual practices, and some claimed that all clients had this infection.

The perception of STIs was more normalized, considering that they were part of active sex life. An MSW living with HIV infection said that hepatitis was more dangerous and destructive than HIV but that the other MSWs were not aware of it. On the other hand, it was noted that there was no talk about STIs or other preventive measures among friends, or in the sauna environment. Also, being under the influence of drugs led to forgetting safe sex practices.

Concerning access to the health system, the difficulties and lack of knowledge about obtaining the individual health card (TSI) were discussed among the barriers. During fieldwork, one MSW who had had a receptive anal penetration without a condom, a high-risk practice of HIV infection, was not given post-exposure prophylactic treatment because he did not have the TSI. On the other hand, there was a perceived easy acquisition of drugs in pharmacies, so it was not surprising that immigrant MSWs who had been residing in Spain or Barcelona for years had no TSI, since they did not consider it especially a priority. When a suspected STI emerged, and they did not go to an emergency care center, they bought the medications they had previously used or followed the advice of a partner. In some cases, those who did not have a TSI and required medical care used the private health system. A Senegalese MSW used medicinal plants for disease prevention shipped from his country.

Concerning the intervention proposals, in general, they expressed low expectations. On the one hand, it was commented that the problem was in the individual who, as a result of loneliness and other social problems, did not care about himself and his health. On the other hand, it was pointed out that they had information to prevent HIV and other STIs and that, also, thank to information and communication technologies, it was easily accessible.

The lack of prevention campaigns was commented, although they were not perceived especially necessary since the “bad life” that some people led generated poor self-care. The sauna was perceived as a place where it was challenging to be healthy. An informant said that the prevention proposals required “removing them from the sauna and taking them to the countryside to see flowers”. The need to facilitate access and supply of condoms in gay leisure venues was noted.

Concerning the Pre-Exposure Prophylaxis, they commented that it was a good measure to prevent HIV, especially for those engaging in SW, although these would lead to decreased condom use. It was also said that some would continue using the condom since this treatment does not prevent other STIs.

Discussion

This is an ethnographic work carried out in a gay sauna that addresses the sexual and social relationships of MSWs from a gender perspective. This study shows that SW is articulated based on masculinity characterized by having multiple sexual partners, a virile appearance, and the ability to generate money as a strategy to achieve status. This pattern responds to a hegemonic cultural model associated with domination, social ascent, and holding hierarchy positions17. On the other hand, the MSW questions the heteronormative model where identity, desire, and sexual behavior coexist in relationships among men. Thus, living in a city like Barcelona allows you to explore and live homosexuality with greater freedom and anonymity, since it has places that facilitate social and sexual encounters among men, such as saunas9. These establishments open options for interactions, where homosexuality and heterosexuality can be drawn together, and to some extent, integrated into the erotic field of same-sex practices18. Indeed, the MSWs that are presented from a heterosexual model feed the erotic fantasy of a rough, strong, and protective masculinity. Moreover, in gay iconography, an essential part of the texts realize that the homophobic cult of virility is not a heterosexual specificity19. On the other hand, the results show, as in other studies, that economic aspects or sexual desires invite the SW20. Also, money is linked to independence and the aspiration of material consumption, which give prestige, control over work, and self-development21,22. Therefore, SW allows achieving an economic and social status that outweighs engaging in a socially stigmatized activity.

The stigma of engaging in SW adopts differences by gender: while in women, the fact of having multiple sexual partners is morally questioned, men are encouraged and even allowed a greater right to leisure and pleasure23. The stigma in them is produced by having relationships with men. Indeed, some young people believe that MSWs become an option to “come out of the closet”, especially for those who had few options to have homosexual relationships in their environment. From a health perspective, it has been shown that there is an association between being attracted to someone of the same sex and worse self-perceived health, more problems with chronic disorders and increased consumption of alcohol and other drugs24. It should also be considered that in a market with precarious work alternatives, it influences the ethnic employment segmentation. That is, immigrant or ethnic minorities’ MSM who experience more significant racism and economic deprivation find a work alternative in the sex market, albeit with a higher proportion of unprotected sex and greater vulnerability to contracting HIV25.

A vital element of this study was to consider sexual orientations, desire, and their relationship with sexual practices in the sauna’s MSWs. Despite adopting an attitude of complacency towards the client, prevention measures were assumed, while this changed with non-commercial sexual partners, whether they were men or women. Those who self-defined as homosexuals engaged in riskier sexual practices in the context of the sauna than heterosexuals, who experienced more significant conflict in this environment. It has been hypothesized that MSWs that are defined as heterosexual or bisexual may have more symptoms of depression or anxiety, respectively, which varies according to the definition of sexual orientation and attitude towards homosexuality26.

On the other hand, situations such as loneliness or lack of supportive social networks were associated with lower self-care. In this regard, it is essential to consider a syndemic approach that allows explaining behaviors from different levels, as well as the social determinants of health27. From this perspective, the importance of having the social support of family and friends has been shown, since the absence of social capital is a factor that promotes risky sexual practices and, thus, the vulnerability to contracting HIV and other STIs28. It should also be noted that STIs are perceived, unlike HIV, as part of a man’s sexual life.

It is also essential to address the issue of drugs, consider the interrelation between the subject, the substance and the socio-cultural contexts in which consumption occurs29 to understand better, for example, the emergence of the Chemsex phenomenon and increasing sexual practices that facilitate the transmission of STIs. Therefore, it would be advisable to exchange knowledge between STI services and drug specialists, as well as identify the reasons that lead people to participate in these practices30.

One of the limitations of this study was not having dwelt further on the MSW’s knowledge about STIs, although attitudes towards prevention and care could be explored. On the other hand, the observation time in the sauna was sufficient and led to information saturation. There are few opportunities to participate so continuously and regularly in this environment, a factor that allowed to create the necessary confidence for contact with informants. Besides, we must consider that studies on MSWs are increasingly complex, due to the use of apps that facilitate sexual contacts with clients online and via meetings in private quarters31.

All of the above allows us to reflect on what SW implies in men. On the one hand, it increases economic and social status, and can even become a platform for emotional networks. On the other, it means entering a world where risk and harm to personal and community health coexist with essential repercussions for one’s well-being. This topic should be further analyzed and include MSWs’ clients since they can provide valuable information on the established power relationships, the mechanisms of economic transaction, and negotiation of sexual and social practices.

In a nutshell, it was observed that risky sexual practices occurred mainly with non-commercial sexual partners. Desire and pleasure mediated relationships, which meant that the MSWs self-defined as homosexuals engaged in less safe sexual dynamics. On the other hand, using drugs, not having a steady partner, and not having supportive social networks are factors that increase the MSWs’ social vulnerability. The interventions for the prevention of HIV and STIs in this group would have to consider the social determinants and needs of the MSWs, create synergy with the owners and workers of these establishments, the health system, community entities and public health in order to respond to complex problems that foster a model of masculinity aimed at better personal and community care.

Acknowledgments

The authors are grateful to the study’s informants and those responsible for the sauna, whose collaboration was essential for this work.

Partial backing was received from CIBERESP.

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Received: November 02, 2017; Accepted: May 11, 2018; Published: May 13, 2018

Collaborations

C Jacques-Aviñó, JA Caylà, O Romaní and PG Olalla collaborated in the design of the project. C Jacques-Aviñó collected data, analyzed and interpreted the results, and drafted the first version of the paper. A Andrés, L Roldán, M Fernández-Quevedo participated in the fieldwork and data analysis. All authors collaborated in the interpretation of the results, performed a critical review of the paper, and approved its final version.

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