University of Southern California Dissertations and Theses

Mexican immigrant women, sex work, and health

(USC Thesis Other)

Mexican immigrant women, sex work, and health

PDF

Download

Open document

Flip pages

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content Mexican Immigrant Women, Sex Work, and Health
By
Armlda Ayala
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree of
DOCTOR OF PHILOSPHY
(Anthropology)
December 1999
Copyright 1999 Armida Ayala
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
UNIVERSITY OF SOUTHERN CALIFORNIA
THE GRADUATE SCH OO L
UNIVERSITY p a r k
LO S ANGELES. CA LIFO RN IA 90007
This dissertatioTir written by
under the direction o f Hb x . Dissertation
Committee, and approved by a ll its members,
has been presented to and accepted by The
Graduate School, in p artial fu lfillm en t of re
quirements for the degree of
DOCTOR OF PHILOSOPHY
iraduate Studies
Date A u g u s t 2 3 , 1999
« # # * • • • • • • • • • • • • • * * • • • • • ■ • • • • • • • • • » • •
DISSERTATION COMMITTEE
Chairperson
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ACKNOWLEDGEMENTS
I thank foremost the Latino men and women who shared their time and
most intimate life experiences which form the basis of this research. I will forever
be grateful for their trust, and for teaching me valuable lessons about the human
condition. I would like to thank all o f the community organizations that supported
me while I collected the data. A very special thanks to Francisco Briones,
Francisco Morales, Marcela Sanchez, Jenell Lagard, and Veronica Morales who
provided the much needed humor, support, and work-space to conduct
participant interviews. I gratefully acknowledge Dr. Lynn Miller, Professor,
University of Southern California, Annenberg School of Communications, who
provided funding for my study through the pre-doctoral training grant from the
Universitywide AIDS Research Program, University of California. I am especially
grateful to Earl Leonard, and Nazleen Patel for their valuable advice and support
in data entry, editing, and analysis.
I am particularly indebted to my committee, Andrei Simic, Gelya Frank,
and Alexander Moore who have greatly contributed to my training and education
at u s e . They encouraged me to pursue my research interests and their advice
kept me grounded in the scope of my dissertation. I thank them for allowing me
to explore the risky areas of sex research while standing firm in the foundations
of anthropology. I thank my committee chair, Andrei Simic, for his time and
guidance during the dissertation process. He provided me with the intellectual
support to bring issues of women, sex work, and health into academic settings.
1 1
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Among my professors and mentors, I am forever thankftjl to Dr. Diego Vigil who
once told me that the “best degree is the one that is finished” and helped me get
through graduate school by providing me with a network of community support.
Sincere thanks to Joseph Carrier, Shiraz Mishra, Raul Magana, and Kevin
O’Reilly for showing me how concepts of applied anthropology are useful in
disease prevention. Finally, I am grateful to Fernando Soriano and Mario de la
Rosa for encouraging me to complete this project.
Among my friends, I am grateful to Rudy Gonzales, Nancy Sabjen,
Concha Barrio, Lupe Guiterrez, and Carmen Rivera who have been there for me
through the most stressful times of this project. I will forever be indebted to my
best friend, Ron Merckling, whose support, loyalty, and patience made my
graduate school years much easier; I could not have made it without him.
Among my family, I am especially grateful to my husband, Jon Heberiing, whose
compassionate love allowed me to complete this project. I would like to thank
Mr. DJ Heberiing, my father-in-law, for his cheerful encouragement and support.
I am indebted to my oldest sister Andrea who has been a powerful force in my
pursuit for a higher education. I am thankful to my brother Cheko and his wife
Anna for their talented help in computer graphics. I will always be grateful to my
youngest sister, Araceli, for her gentle, unconditional love. Finally, I dedicate my
dissertation to my parents, Santos and Alberto Ayala, and my whole fam ily who
gave me a safe space, lots of love, great food, and quiet walks under the desert
stars during the most trying times of my dissertation.
Ill
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
TABLE OF CONTENTS
Chapter 1 Introduction
HIV/AIDS: A major local health problem
The relevance of the research
Theoretical Framework
Chapter 2 Literature Review . . . . .
The health of Mexican Americans
Decision-making, gender, and the political economy.
Mexican Immigrants in Los Angeles .
Women and sex work. . . . .
Women, migration, and family life
The bidirectional model as practice .
Chapter 3 Methods
The ethnographic process
Research design
Study site
Study setting: the cantinas
The sample
Chapter 4 Presentation of Data . . . .
Sociodemographic profile of sex workers and their customers
Sexual history and sexual practice .
Adoption of contraceptives . . . .
HIV/STD prevalence and prevention methods practice
Alcohol and drug use . . . . .
Adaptaüon of tiie study population to the host community
Violence and sex work . . . .
Sex work as survival . . . . .
Conditions of the workplace . . . .
Housing condiüons
Chapter 5 Conclusions. . . . . .
Conclusions . . . . . .
Reccomendations . . . . .
Bibliography . . . . . . .
1
1
6
10
19
19
33
44
60
64
67
73
75
81
93
98
102
107
107
112
117
123
135
136
139
143
150
157
163
164
182
192
APPENDICES
Appendix A: Biographical Profiles .
Appendix B: Study Questionnaire .
Appendix C: Bidirectional Model
210
218
233
IV
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
LIST OF TABLES
Table 1 Characteristics of Long Beach Compared to LA. County 96
Table 2 Characteristics of the Sample Compared to the Long Beach 109
Table 3 Sexual History 112
Table 4 Adoption of Contraceptives 117
Table 5 HIV/STD Prevalence and Prevention Methods Practice 123
Table 6 Reasons for Not Using Prevention Methods 127
Table 7 Alcohol and Drug Use among Sex Workers and their Customers 135
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ABSTRACT
This dissertation addresses the context in which Mexican immigrant sex
workers in cantinas (bars) make decisions leading to the adoption o f methods for
contraceptives and the prevention of the Human Immunodeficiency Virus (HIV)
and Sexually Transmitted Diseases (STDs). The study population is composed
of mainly Mexican immigrant sex workers and their male patrons in an urban
setting of Los Angeles County, California. The context in which the study
population makes decisions about HIV prevention and contraceptives is
discussed from a micro and macro level of analysis. These two levels of analysis
are used to examine how environmental forces including social, economic, and
political affect the way the study population makes decisions about preventing
HIV/STDs or pregnancy and how the population adjusts and manages health
problems related to this context.
The interrelationships between the environmental forces and those
internal ones such as the roles women and men play in decision making for
HIV/STD prevention and contraceptives is evaluated. Critical factors in this
interface include the recent immigrant status, the structure of the recent
immigrant health care system, women’s roles, the socioeconomic status,
occupation, and the sociocultural context in which the study population makes
decisions about adoption of HIV/STD prevention and contraceptives. This study
carefully examines the roles, sexual behavior, use of contraceptives and
STD/HIV prevention, and how these relate to the individual’s socio-economic and
VI
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
political context, utilization of health, and immigration to the United States. Due
to the lack of access to health care, compromised economic status, and
geographic and cultural isolation of the study population, the role that women
play has increased their independence in their choices about contraceptive use
but lessened their ability to make decisions about HIV/STD prevention. The
women’s high risk for HIV/STD infection is related to their lack access to health
care and HIV/STD prevention as a result of local policy and lack o f prevention
efforts targeted to this population.
Vll
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER 1
INTRODUCTION
Health care policy regarding HIV/STDs {Human Immunodefficiency
Virus/Sexually Transmitted Diseases) in Southern California has the challenge of
reaching multicultural populations that are somewhat hidden such as immigrant
sex workers in cantinas (bars) and their customers. The thesis of this
dissertation is that appropriate interventions require closer understanding of how
culture (i.e., Mexican Immigrant’s beliefs about health and their sexual practices)
Is related to sexual behavior among hidden populations. However, It Is important
to expand such a study to include the soclo-structural (i.e., political, economic,
and migratory) forces that drive women into sex work and influence their
decision-making about the use of prevention methods for sexually transmitted
diseases.
HIV/AIDS-A Major Local Health Problem
Despite Increasing rates of AIDS {Acquired Immunodefficiency Syndrome)
among Latina women in the US (Amaro 1995), few studies have been conducted
on the prevention of HIV {Human Immunodefficiency Virus)/STD {Sexually
Transmitted Disease) or on the contraceptive practices of Mexican Immigrant
women. The sexual practices and attitudes of Mexican women working in
cantinas as sex workers and their customers have not been studied at all (Ayala,
Carrier, & Magana 1996:96). The incidence and prevalence rates o f HIV/STD
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
among this subgroup are difficult to establish although obviously important
epidemiologically.
The few available studies that have been conducted on HIV/STDs and sex
workers in general, have been predominantly focused on street, drug-addicted
sex workers that, unlike immigrant sex workers, trade sex mainly for drugs rather
than survival (Magana 1991; Ferreira-Pinto, Ramos & Shedlin 1996; Organista &
Balls-Organista 1997). High partner exchange and paying for sex are frequently
observed practices among immigrant males. Since female sex workers in
cantinas are sporadic sexual partners of these immigrant men who practice high-
risk behaviors, the women are particularly at risk for contracting HIV/STDs. This
study focuses on the attitudes and practices concerning prevention of HIV/STDs
among female sex workers and their customers in the city of Long Beach,
California, based on ethnographic interviews and a quantitative survey in the
years 1990-1997.
My main goal in conducting this study is to provide information to reduce
the risk for HIV among female sex workers and their customers. Local
community-based organizations can use this information to develop interventions
to reduce the further spread of HIV/STDs among sex workers in cantinas, their
customers, and the general public. This information can also help to prevent the
high cost of treatment associated with AIDS. My research provides an
understanding about the need for knowledge of the socio-structural and cultural
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
factors that drive sexual behavior and present risks for HIV/AIDS among the
study population. The way in which socio-structural forces such as poverty and
health care policies interact with the culturally specific sexual practices of sex
workers and their customers contribute to the potential spread o f HIV among this
population
My work with Mexican immigrant female sex workers shows that women’s
roles and the economic context in which sex work is practiced critically determine
the risks they are willing to take even when they are knowledgeable about
prevention. First, women in my study were more likely to be fam ily providers in
contrast to a dependent family member. Ninety five percent (95%) of the women
interviewed reported being the sole provider for their household. All of the
women reported migrating to the U.S. alone and making all decisions related to
subsistence for themselves and their families. Second, women had more control
of their contraceptive use than their male sexual partners did. All o f the women in
the sample reported being the primary decision-makers for the type of birth
control they adopted. Women were the main decision-makers in adopting birth
control primarily because they wished to avoid unwanted pregnancy and the
burden of supporting another child. Additionally, they could easily take birth
control pills but had more difficulty persuading men to wear a condom; thus, the
primary responsibility for contraception belonged to women.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Third, women had much less control o f their method of HIV/STD
prevention compared to contraception. This was due to their degree o f economic
need. Their power in this area was weakened by certain practices specific to
them as women in their culture. Only twenty five percent (25%) o f the women
reported being the primary decision-maker in choosing STD prevention methods
such as condoms. T heir reduced role of decision-maker when choosing a
prevention method fo r HIV or STDs was the result of negotiating unsafe sex with
customers willing to pay more money for sex without a condom. Sixty five
percent (65%) of the women interviewed reported exchanging sex without a
condom with a customer because they needed the money. This apparent
contradiction, of being the primary decision-maker for birth control but not for
condoms, which are also a form of birth control, is easily understood since taking
birth control pills is unobtrusive and in no way evokes the displeasure of a male
customer. Condoms are also more expensive than birth control pills and many
women could not afford them.
I argue that it is important to study not only sex workers, but also their
customers because this information can help explain the context and meaning of
sexual behavior for a better understanding of high-risk sexual practices in
general. It is also a key issue in disease prevention efforts because customers
often see sex workers as responsible for the spread of HIV. The men in my
study, for example, manifested contradictory beliefs about hygiene and
transmission of disease. On the one hand, the men who buy sex in my study
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
perceived sex workers in cantinas as “cleaner” (a woman who is less likely to be
infected with HIV/STDs) than street sex workers, because, unlike street workers,
they did not inject drugs. On the other hand, they still believed that sex workers in
cantinas were as likely to infect them with a STD because they were still “putas"
(whores). This paradox existed because men who buy sex did not see
themselves as vectors of transmission; they perceived sex workers as those
responsible for infecting them. I strongly argue that the trend of HIV increase
among women in general and my female study population is likely to continue
because women are more likely to contract the disease from an HIV-infected
male than men from an HIV-infected female. In other words, the transmission
from male-to-female is more frequent than female-to-male, and women are likely
to encounter difficulty in negotiating safer sex practices with men.
The difficulty in negotiating safer sex practices for these women is even
more complex due to social forces exacerbating their risk fo r HIV. Social forces
are defined here as: poverty, lack of access to health screening and testing for
sexually transmitted diseases (STDs), attitudes toward immigrants, attitudes from
customers and public health toward sex workers, lack of culturally competent HIV
prevention programs, and political conflict. The social forces that posed
HIV/STD risks for my study population were economic and political in nature.
Poverty was the strongest factor for risk of exposure to HIV. My study showed
that immigrant sex workers were living in extreme poverty, lacked access to
health care, had no health insurance, and did not access HIV prevention
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
programs. All of these women were driven into prostitution by poverty. All fled
economic oppression or some other problems in their country of origin and were
responsible for supporting their fam ilies and their children. These women are
also at risk for a multitude of other health problems including violence, stress,
unwanted pregnancy, and other sexually transmitted diseases besides HIV.
The Relevance o f the Research
Mexican immigrant women working in cantinas as sex workers and their
customers have been a hidden population and underserved by health care
service providers and researchers. T he dilemma of restricted access to health
care and limited attention to this population has been raised in the literature of
Latina women in HIV/AIDS, sex work, and health in general (Amaro 1995; Marin
1995; Skjerdal et al. 1996; Ferreira-Pinto, Ramos & Shedlin 1996; Bronfman &
Lopez 1996; Mishra et al 1996 and Organista & Balls-Organista 1997;).
Nevertheless, it has never been addressed in terms of Mexican immigrant sex
workers in cantinas.
The work of these authors outi ines the relationship of factors affecting the
health of Latina women engaged in sex work in the United States. The Latino
population in the U.S. has been disproportionately affected by sexually
transmitted diseases, including HIV/AIDS. Latina women, for example, have the
second highest rate of exposure to At DS through heterosexual transmission
(Marin 1995; Skjerdal et al. 1996; Organista & Balls-O rganistal997).
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In California, trends indicate that the epidemic is growing most rapidly
among African American and Latino populations. Cumulative AIDS cases among
Latinos rose from 17% in 1994 to 21% in 1995. Approximately 63% of Latinos in
the U.S. are of Mexican origin, and a substantial number of these are
concentrated in California, one of the states with the highest incidence of
HIV/AIDS. Latinos in California number more than ten million, constituting the
largest minority population in the state (California Department of Health Services
1996:8). These figures are likely to increase because of the shared border and
because Mexicans who immigrate to California have been documented to stay in
the U.S. longer than those who travel in other states (Rojas 1997:3).
These findings are consistent with those on AIDS cases found in Long
Beach where my study was conducted. For all reported adult/adolescent female
AIDS cases in Long Beach, through December 31, 1996, heterosexual contact
was the leading category for exposure (41%). Since 1982, women comprised
4.7 % o f all reported AIDS cases in Long Beach. For the year 1996, however,
women represented 9.3% of AIDS cases. This suggests a strong trend in the
number of female-infected AIDS cases in Long Beach. Latinos in Long Beach
are becoming HIV infected at a greater rate than any other ethnic group except
African-Americans in proportion to the total Long Beach population. Moreover,
the rate of AIDS cases in Long Beach is nearly twice the rate for Los Angeles
County and over two times the rate for the state of California, suggesting an even
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
greater impact o f AIDS transmissions for Latino women in Long Beach (City of
Long Beach, 1998: 33).
Mexican-origin immigrants in California are, hence, becoming a high-risk
group for contracting sexually transmitted diseases including AIDS (Skjerdal et
al. 1996:40). Research indicates that a set of factors associated with immigrant
living conditions such as the lack of access to health care, poverty, constant
mobility, hazardous work settings, and under-employment, have a negative
impact on the management of their health (Organista & Balls-Organista 1997:83-
937). Their increased HIV risk is attributed to their lack of access to health care
and exposure to street and work-related violence. They also have unprotected
sexual intercourse and a high incidence of poverty. To an alarming degree,
sexually transmitted diseases disproportionately affected sex workers in my
study, and their every day survival needs took precedence over concerns of
sexual practices and prevention of HIV/STDs.
The importance of immigrant women's sexual labor has been de
emphasized in the study of Mexican immigration. This is particularly important
given that much of the literature on Mexican migration and immigration to the
U.S. has highlighted the importance of Mexican labor to the United States
economic system and has treated Mexican immigration as labor migration (Clark
1959; Fernandez-Kelly 1983; Chavez et al. 1986; Chavira-Prado 1992;
Hondagneu-Sotelo 1994). Studies that focus on the migrating populations have
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ignored some of the social implications of immigration affecting women such as
the reasons why women migrate to the U.S. and how they end up in a highly
hazardous occupation: commercial sex work.
Ferreira-Pinto. Ramos and Shedlin (1996) who present relevant
demographic data on the ten most populous counties of the border region
between the United States and Mexico call for more research on the sexual and
drug behaviors of sex workers on both sides of the border. According to these
researchers, forty percent of the ten poorest metropolitan areas in the United
States are located in the U.S.-Mexico border area. This high level of poverty,
homelessness, and other forms of social displacement affect the decision of
Latino women to become sex workers (Ferreira-Pinto, Ramos & Shedlin,
1996:115). These authors further document that in these same ten counties,
Imperial and San Diego Counties contain the highest percentage of poor Latinos
(Imperial County) and the most cases of HIV (San Diego County) both located in
Southern California two to three hours from Los Angeles. These two counties
contiguous with the U.S.-Mexico border in Southern California are separated by a
political boundary but are united by many shared economic, cultural, and social
traits. Latinos in this region are for the most part, a young population aged
fourteen to twenty-four years. Compared with other counties, San Diego reports
the highest number of HIV infection among the overall population (Ferreira-Pinto,
Ramos & Shedlin 1996:112).
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Latinos and Americans along the U.S.-Mexico border in Southern
California, live in constant bi-national contact, working in agriculture, industry,
and buying and selling, including sex (Ferreira-Pinto et al. 1996:111). With the
ratification of NAFTA (North American Free Trade Agreement), there has been
an increase in the population in the border region as a result of the “maquiladora"
industry. These maquiladoras are plants for assembly and light manufacturing
owned by U.S. companies and located on the Mexico side of the border. These
companies have increased migration from the interior o f Mexico to U.S.-Mexico
border cities such as Tijuana and Mexicali, Baja California, attracting migrants in
search of employment in these cities and in the U.S. (Ferreira-Pinto, Ramos &
Shedlin, 1996). Until recently, single, Mexican males comprised the highest
percentage of those migrating to the U.S. (Bronfman & Lopez, 1996). This
migratory trend is changing as more single women are also migrating to the U-S.-
Mexico border and to the U.S. (Mishra et al.. 1996). It is at this intersection that
women, often failing to secure employment in the private, formal sector of th0
labor force, resort to sex work fo r survival.
Theoretical Framework-The importance of Social Analysis
Medical anthropologists have traditionally studied small-scale, rural,
underdeveloped cultures rather than the large, urban societies in which they
themselves are active participants. Early medical anthropologists such as
Margaret Clark, George Foster, Octavio Romano, Arthur Rubel, Lyle and
Saunders, and focused on ethnomedical research among Latinos (Browner
10
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
1994:468). Although their work focused on the folk and popular health care
sectors— especially on the culturally distinctive beliefs and practices as evidence
o f the survival of indigenous traditions— they shifted medical anthropology from
small-scale, exotic studies into the social arena of complex societies where
people from poor, rural backgrounds were now living.
More recent work such as that of Baer et al. (1986), Morsey (1990), Doyal
(1995), Chavez et al. (1992, 1995), Singer (1992, 1996) and Roberts (1999) has
begun to examine health from a political-economic and gender perspective.
Political economic theory focuses on large-scale regional political and economic
systems and their impact on specific communities (Ortner 1994:386). The effects
o f external forces such as capitalism, and the ways in which specific communities
respond to them are often emphasized. This framework combines this macro
analysis with fieldwork to inquire about symbols that represent class, gender, and
identity in the context of political or economic struggle; it is centered on economic
exploitation, wage, and underdevelopment. For example, Mexican immigrant
men practice drinking and extramarital sex in their cultural macho role, which
then take place in the cantina. The cantina is their symbol and venue of where
the flow of capitalist consumption (i.e., alcohol and sex) is maintained.
Moreover, Doyal (1995) and Roberts (1999) argue for a gender political
economy. Doyal (1995) contends that this gender sensitive theoretical
framework is critical because the economic inequalities in the division of labor
1 1
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
seriously affecting women’s health. For example, sex work, usually assigned to
women In Mexican culture and society, can be financially and physically
debilitating especially If It Is done with Inadequate resources (I.e., limited access
to condoms) and combined with pregnancy or other work outside the household.
Roberts (1999) argues along the lines of a political economy o f health because
both the demand for and supply of health and health care are gendered. For
example, health care Is rationed to women and their children, the largest
population of uninsured persons, because their position In society as mother and
wife, rather than as citizens In their own right, denies them access.
Morsey argues that a political economic framework Is crucial because
medical anthropologists bring Into focus how global power relations pertain to
local health systems. By doing this, Morsey contends that a political economic
perspective does not deny cultural specificity but rather It reinterprets the concept
of culture (Morsey In Johnson & Sargent 1990:26-27). Baer et al. (1986) defines
the political economy as “access to and control over the basic material and non-
material resources that sustain and promote life at a high level o f satisfaction “
(Baer et al. 1986:95). Patients must struggle to maintain their health In a
capitalist society that denies access to those who cannot afford; the III are
marginalized because they do not contribute to the production and consumption
of commodities (Baer et al. 1986: 94).
12
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Women, immigrants, minorities, and the poor who have limited access to
health care suffer inferior health compared to those who are more privileged and
have the resources to obtain health care and sustain good health. All the
participants in my study were immigrant women and men who lacked health
insurance, lived in extreme poverty with income levels approximately between
$500-1200 per month for a family of four, and lacked access to HIV testing and
prevention services. The experience of Sofia Torres (pseudonym), a sex worker,
is an example of their highly marginalized and vulnerable status:
Sofia was born in Mexico and lived in one of the most impoverished areas
of Long Beach. She was twenty-five years old and did not speak English.
She worked in one of the local cantinas as a sex worker. Sofia suspected
that she had became infected with HIV thorough her husband who was an
injecting-drug user. She reported never using condoms with her husband
who often refused to do so. Sofia worked as a sex worker with her
husband’s knowledge and supported his drug habit; she often worried that
she might infect her husband with a sexually transmitted disease. She
also reported not knowing that her husband was infected with HIV. Three
years ago, Sofia and her one-year old daughter were diagnosed with HIV.
She had limited health insurance and was unable to gain access to
expensive anti-viral treatment to avoid the progression of HIV into AIDS.
Sofia was unable to work due to her illness and reported that she had
been denied disability insurance because she did not have a T cell count
under 200 to qualify. Unable to secure health insurance and a steady
income to deal with the progression of HIV, Sofia and her baby girl died of
AIDS four years after being diagnosed with HIV.
The current political climate in California further complicates problems for
implementing sexual and reproductive health prevention programs targeted for
immigrants. This is likely to be even worse if Proposition 187, an anti-immigrant
statute for which a majority voted 1994, limiting health services to immigrants is
upheld by the courts. Many programs that have traditionally provided health
services to this population are already experiencing major financial restrictions
13
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
and others are on the verge o f disappearing. Optimization o f existing resources is
urgently needed, both for improving the quality of life among this population and
for controlling highly transmittable health problems, such as HIV and other STDs.
From a political-economic perspective, I argue that ill health stems from socio
economic factors resulting from immigrant worker's marginal participation in
capitalist modes o f production. In the case of Sofia, she was unable to
participate in the labor force due to her illness, and thus unable to secure the
financial resources to consume the health care services she desperately needed.
Chavez (1992, 1995) argues that immigrants are often employed in jobs
that do not offer insurance benefits and are dangerous to Latino’s health, thus,
making them more vulnerable to disease. Singer (1992) raises several critical
questions that hit very close to my research:
W hat can and should be anthropology’s response to the fact that AIDS is
fast becoming the leading cause of death for people of color in the US?
How should we, as anthropologists, react to the projections that by the
end of this year (1992), 180,000 people in the US will have died of AIDS
and that the percentage of cases among African Americans and Latinos
will be more than double their proportion of the total US population?" (p.
89).
With these questions in mind, I asked myself: Why does AIDS affect poor women
of color so disproportionately? Like Baer et al. (1986), if one thinks o f health in
political terms as access to and control over the basic material and non-material
resources that sustain and promote life at a high level o f satisfaction, then one’s
gender, race, and class is critically linked to one’s well-being. W ithin this
14
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
framework, an individual must struggle to maintain his/her health in a society that
denies access to those who cannot afford it.
Several social forces shape the HIV epidemic among Mexican immigrant
women living in Long Beach where AIDS is highly prevalent. I contend that our
social analysis should be combined with ethnographically informed observations,
so that epidemiologists can do a better job o f identifying significant factors
resulting in the high rate of HIV/STD transmission among the study population.
My social analysis is based on the factors o f poverty, racism, sexism, lack o f
structural support, traditional patterns of sexual behavior, and political conflict.
The most influential of these, however, is poverty. Women’s decisions
concerning methods of HIV/STD prevention must be understood in terms of the
women's position within the family, society, and political economy. Such a
theoretical stance is in keeping with anthropological principles, which call for a
holistic approach, placing individual's behavior within its socio-structural context.
Thus, a detailed ethnography is needed to grasp the entire spectrum of the
fem ale domain in which they participate. All this must, finally, be placed within
the macro-level context of global capitalism and international policy which
dictates migration to the U.S. and determines the conditions which ultimately lead
women into sex work and its dangerous practices.
Women in the sex industry have been generally portrayed in the
epidemiological literature as vectors of disease from whom customers must
15
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
protect themselves (Rosenberg et al. 1988; Darrow 1992; Estebanez et al. 1993;
McKeganey 1994; and Pyett & W arr 1997). However, sex workers play other
roles in various social and economic contexts, which are seldom researched
(Hart, 1996: 139). In this work, I demonstrate that the literature on HIV/AIDS and
sex work perpetuate biases against these women. The literature on sex workers
tends to view them as reservoirs of disease while ignoring social, political, and
economic realities of their work lives. It should be no surprise that all of the
female sex workers in cantinas (bars) whom I interviewed in Long Beach
reported that they were driven into prostitution by poverty.
My data collected in Long Beach demonstrate that a woman’s role as wife,
lover, mother, sister, and daughter is an integral part of her career as a sex
worker. Such a perspective is necessary for the development and
implementation of effective prevention programs targeting immigrant women in
the sex industry. The ethnographic data help to make the case that sex work
must be viewed as a job and that it must be regulated to protect the health and
lives of women in these settings. This research, then, aims to add significant
dimensions to the ways in which state and county public health officials, as well
as epidemiologists and other scholars, perceive commercial sex workers and
implement HIV and STD prevention programs.
As the following chapters show, the women I studied were primary fam ily
providers, and they exemplified the increased migration of women independently
16
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
to the United States for economic reasons rather than to follow their husbands
and/or families. Simultaneously, these economic activities extend the women’s
role as that o f the caretaker on issues of health and subsistence (Chavira-Prado
1992; Donato 1993; Salgado de Snyder 1994; Barchas 1998). It became evident
that the social, economic, political, and cultural contexts, in which these women
engage in sex work, dictate their lack o f control over adopting HIV/STD
prevention measures. The circumstances in the host community including
employment and health care needs, set the high frequency with which women
exchange unsafe sex for money or survival, and how they gain access to health
care, specifically primary care and HIV/STD prevention.
SUMMARY
This chapter introduces some o f the most complex issues related to HIV
risk among Mexican immigrant sex workers in cantina (bar) settings in a study I
conducted in Long Beach. Mexican immigrant women are part of the latest trend
among women at risk for HIV and other sexually transmitted diseases in the U S
and In Long Beach. Aside from the cultural-specific norms such as the power
imbalance between men and women to negotiate safer sex, social forces, such
as poverty, lack of access to prevention programs and health care, interact to
complicate this problem even further.
My study found that Mexican sex workers in cantina settings were driven
to sex work by poverty, had little power in making decisions about adopting STD
17
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
prevention measures, lacked access to health care, and dealt with a multitude of
other health problems and barriers to sustain good health. Another major issue
in this regard, was patterns of traditional Mexican gender and class relationships.
This research is long overdue not only because there is a lack o f information
about this population, but also because it can be useful for the development and
implementation o f HIV programs to prevent the further spread o f HIV to this
population and the general public.
I employ a theoretical political economy framework for examining this
population because it addresses the issue of agency and a macro-level analysis
that organizes social analysis with ethnography to identify significant factors
resulting in the high rate of transmission of HIV and STD among the study
population. This approach is helpful because it allows us to see the lives o f
women behind the statistics and provides a more humanistic approach to
understanding the risk women take to survive while engaging in commercial sex
work. This study will show the complex interaction of socio-economic and
cultural forces that affect the destinies of Mexican immigrant women.
1 8
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER2
LITERATURE REVIEW
This chapter reviews the research on Mexican immigrant women, sex
work, migration, economic, and sociostructural issues and how they make
decisions related to their health. This literature while not very large builds on a
more extensive set o f studies centered from 1950 to 1998 of Mexican immigrants
and Mexican Americans in a variety of settings. A detailed analysis of the health
problems encountered by Mexican immigrant women is formulated within the
framework of this literature review, with special emphasis on the practice of bi
directional health care.
The Health of Mexican Americans
The first major trends in the literature regarding Mexican Americans,
immigration, and health issues appeared from 1950-1970. The work of Foster
(1953), Saunders (1954), Clark (1959), Romano (1965), Rubel (1966), Madsen
(1961, 1964), Kiev (1968), and Mackling (1978), provided a foundation for
valuable, future ethnographic research on Mexican Americans and Mexican
immigrants. Major contributions included such issues as the need to consider
cultural differences in health care utilization and delivery documentation of
traditional folk medicine and women’s roles in these traditional practices, low
19
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
health status as a need for intense intervention, and the documentation of the
effects of poverty on health.
Acculturation has been a classic concept in anthropology as part of
immigration over the years, where the solutions to the health problems of
Mexican Americans were viewed as resulting from their own Americanization or
assimilation in Anglo culture. The classic work of medical anthropologists from
the 1950s to the 1970s on the health issues of Mexican or Mexican Americans,
as presented above, focused on ethnomedical research and acculturation.
Studies from these researchers tended to be micro explanations of behavior that
generalized the health beliefs and behaviors of the Mexican immigrants and
Mexican American populations. For example, Foster's early work focused on folk
medicine in the analysis o f the health practices of Hispanics (Foster 1953: 201 ).
Along the same lines, Saunders focused on rural studies of Mexican American
health and illness, and analyzed the cultural health beliefs of Latinos in
relationship to the effective utilization of health care. In other words, cultural
beliefs and behaviors were related to the health conditions of Mexican Americans
(Saunders 1954:104-105).
Romano also studied folk healers in respect to the utilization of health care
providers by Mexican Americans. He proposed that Mexican Americans often
seek medical care in a healing hierarchy ranging from relatives to folk healers,
and then to medical doctors. His work, nevertheless, lacked a structural analysis
of health utilization among this population (Romano 1965:1154-1158). The
2 0
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ethnographic work of Clark (1959), Madsen (1964), and Rubel (1966) continued
this micro-centered model. Subsequent researchers referred to the w ork of
Rubel and Clark as focusing on folk and popular health with little analysis of the
variability o f these practices in respect to the society's distribution of resources.
Clark’s work was criticized for failing to recognize diversity among Latinos and
emphasizing cultural factors as the main reason for social conditions while
overlooking the political economy and social structure (Browner 1994; Melville
1980; Alvarez 1971; and Paredes 1978).
Like Saunders (1954), Clark (1959) analyzed Mexican American folk
beliefs but she focused on urban settings rather than rural ones. She continued
working with a micro perspective concentrating on folk health-related beliefs such
as the hot and cold theory and culturally rooted communication barriers to the
utilization of mainstream health service providers. Clark’s reference point was
that health-related cultural beliefs and communication barriers with service
providers adversely affected the access of Mexican Americans to health care and
service delivery. In spite of the fact that Clark gave some small mention of
economic factors contributing to lack of access to health care, the effect of socio
cultural barriers were left unexamined in her work.
Madsen (1965) focused on socioeconomic class and its effects on health-
related cultural beliefs and behaviors. Madsen suggested that although
anglicized, higher social class Mexican Americans resorted to folk medicine less
2 1
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
than their counterparts, utilization of folk medicine cut across all classes among
Mexican Americans. Madsen, thus, continued what might be called a
“culturaiist” approach that failed to offer a complete sociostructural and economic
explanation of health behavior among Mexicans. Madsen concluded that
Mexican Americans, in spite of having access to health care by virtue of enjoying
a higher-class status, would still resort to folk medicine due to strong cultural
mandates. Rubel (1966) continued with the culturalist tradition established by his
predecessors. Rubel’s focus remained on folk medical beliefs and practices
reflecting in the early works of Saunders, Clark and Madsen. However, Rubel’s
(1992) recent work on tuberculosis, touched upon the complex, socio-cultural
factors that result the delay in seeking treatment for tuberculosis among Latinos,
and he also acknowledged the lack of studies of more complex, sociocultural
factors. Of this, Rubel commented:
The twin problems of delay in seeking treatm ent and abandonment of a
prescribed regimen derive from complex factors. Cost of transportation,
organizational problems in providing adequate follow-up services and
patients’ perceptions of clinic facilities as inhospitable all contribute to this
complexity. Sociocultural factors are emphasized in this report because
hitherto they have not been adequately explored (Rubel & Garro
1992:626-636).
Culturalist studies from a micro-level perspective continued to appear well
into the late 1960s and 1970s, and strongly suggested that certain pathological
cultural traits of Mexican Americans interfered with proper health care utilization.
Studies of mental health, for example, suggested that the cultural effects of the
fam ily upon the individual were damaging to the individual’s effective use of
2 2
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
clinical treatment (Nall & Spielberg 1967; Kiev 1968). For example, the cultural
practice of Mexican Americans such an emphasis on strong fam ily ties out o f
which came the cultural tendency to hide and insulate the patient from clinical
treatment (Nall & Spielberg 1967; Kiev, 1968). In contrast to this pathological
orientation, Kiev (1968) proposed that Mexican curanderos (folk healers) w ere
successful folk psychiatric healers because they worked within the patient’s
framework. Kiev argued that curanderos reintegrated the patient into his/her
cultural milieu, whereas Anglo psychiatric treatment involved separating the
patient from society. For this reason, Kiev's work reinforced the traditional
theoretical approach to Mexican American health research, and his work
stimulated the emergence of holistic approaches which departed from the
pathological depiction of Mexican Americans as culturally deprived (Montiel
1970:56). Mackling (1978) focused on the relations between the role of women
and traditional folk medicine in Mexican American culture on both sides of the
US-Mexico border (Mackling 1978: 155-163). In spite of her culturalist views,
Mackling contributed to an analysis of the role of Mexican and Mexican Am erican
women as healers, revealing aspects of the female role often ignored by
researchers (Mackling 1980:127).
The classic works in anthropology from a “culturalist” framework though
important, left three common themes unapprised: 1 ) a macro-level analysis o f
society's effect upon the health of Mexican Americans, the larger context and its
impact on beliefs and values, and health care utilization and delivery; 2) an in
23
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
depth analysis o f the role of women in the healing process; and 3) the issue of
Mexican immigrants and health in particular. Cultural differences between the
Anglo health care system and practices and beliefs of the Mexican American
population were well documented with no reference to the lack of participation by
this population in that system. Economic issues remained unexplained such as
the high cost of health care and a lack of resources stemming from poverty that
resulted in under-utilization o f health care by Mexican Americans. Health care
delivery as a primary responsibility of health care providers also remained
untouched. Instead, these researchers focused on issues o f acculturation or
Americanization, as if it were the key to the solution of the health problems of
Mexican Americans.
The basic assumptions regarding the macro-economic structure in which
health problems for this population were generated was left unchallenged.
Subsequent researchers such as Chavez et al. (1992), Ginzburg (1991), and
Valdez et al. (1993) have more recently begun to address this issue of macro-
economic structure more carefully. Chavez et al. (1992) in their study of
undocumented Mexicans and Central Americans in Southern California found
that the parameters of political economy greatly affected the use and nature of
health care sought by immigrants. For example, lack of health insurance and
fears emerging from lack of documentation impedes using services; however this
also increases the use of emergency services due to exacerbation of
preventable/treatable disease such as chicken pox, pneumonia, and infection.
24
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Along these lines, GInzberg (1991) looked at the more general factors involved in
Latino health care access such as socioeconomic status, demographic
determinants (age of population, income, birthrates, etc.), health facility locations,
and the paucity of Latino health professionals. In a more focused work of socio
economic issues, Valdez et al. (1993) explored how financial, structural, and
institutional barriers (i.e., environmental resources for survival, violence issues,
work conditions, and the realities o f poverty in general) affect the utilization and
perceived utility of health services traditionally available to Mexican Americans
and immigrants. Such findings suggest that understanding of health needs of
this population and providing the appropriate services require a greater range of
inquiry than have been provided by previous research.
One major area o f inquiry to be expanded beyond the limits o f simple
recognition is the role of women in health (Chavira-Prado 1992). It is common
knowledge among Mexicans and Mexican Americans that women play an
important role as health care providers in the family, yet some researchers have
neglected to explore this role in relation to urban studies. It was not until
Mackling focused on the relations between the role of women and traditional, folk
medicine in Mexican American culture on both sides of the border that this issue
was touched slightly, but only from the same micro-level viewpoint (Mackling
1980: 127). A number o f questions were left unanswered in the literature, such
as: How do poor, immigrant women provide health care for themselves and their
fam ilies in an urban context? W hat social and structural barriers do poor,
25
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
immigrant women face when trying to gain access to health care? Do service
providers play a role in interfering with the access to health care for these
women? The classic works also tended to over-generallze Mexican American
health issues to all other Latinos including Mexican immigrants. The
heterogeneity of Mexicans and Mexican Americans went overlooked. Most of the
conclusions In these works were based on anthropology’s tradition of study with
small-scale, homogeneous cultures that In this case, were small rural groups of
Mexican Americans. Demographics, which are key factors affecting cultural
beliefs and values, and which In turn affect health care use and delivery, went
unnoticed. These factors Include a population’s length of urban residence, level
o f acculturation, age, occupation, education, place of birth, social class, and
others.
The Paradigm Shift to Sociostructural Perspectives
From the late 1960s to the present, there has been a paradigm shift from
a micro-level o f analysis to macro-level explanations of the health of Mexican
Americans. The culturalist model, which concluded that cultural reasons were
the result for Mexican Americans low health status, was finally refuted. The
emerging works (Moustafa & Weiss; Karno & Edgerton 1969; W eaver 1969; Kay
1977; Melville 1980; Manzanedo et al.1980; Velez-lbanez 1980; Alvarado 1980;
GInzberg 1991 ; Modiano 1992; Singer 1992; and Chavez et al.1992) began to
deviate from their culturalist predecessors. These researchers examined the
structural barriers faced by Mexican immigrants and Mexican Americans while
26
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
using health care services. Their frameworks relied much less on ethnographic
research, but rather on mixed quantitative and qualitative methodologies. Their
work documented the lack of cultural sensitivity in health care delivery and the
lack of health facilities as barriers to the utilization of health care. Lastly, they
paid more attention to the heterogeneity o f Mexican Americans and Mexican
immigrants in the US as it affected health beliefs and practices. They also highly
emphasized urban studies to avoid the rural stereotype. This is not to deny the
value o f ethnographic research. Major contributions to social science by classic
ethnographic work included documentation o f conditions demanding the need for
consideration of cultural differences in patterns of health care utilization and
health care programming, the low health status, of the populations studied and
the need for improved health.
Researchers like Moustafa & W eiss (1968) brought more attention to the
diseases of poverty such tuberculosis, that were most common among the
Mexican American population along with highest rates of infant mortality. This
was attributed to the majority of the population belonging to the lower
socioeconomic class, which affected under-utilization o f clinical health care
facilities. Lower socioeconomic status was correlated with low health status and
with reinforced cultural beliefs and practices which prevented clinical health care
use (Moustafa & Weiss 1968). The heterogeneity of the Mexican American
population Is a critical population characteristic posing particular methodological
problems that must not be overlooked. Varying levels of assimilation and
27
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
acculturation, language skills, education, socioeconomic status, generation of
US-born, occupation, and age, critically affect cultural beliefs and practices
related to health that also can affect health status and availability o f clinical
health care resources (Moustafa & Weis 1968). Folk medical lore was examined
to determine the level of cultural influence on health practices (Kay 1977).
Cultural differences between patients and health care providers and cultural
tendency to fear agency officials were used to explain why Mexican Americans
were not gaining access to health care (Weaver 1969; Kay 1977; Kamo &
Edgerton 1969).
These studies began to explore Mexican Americans’ attitudes about the
effectiveness and the importance of clinical health care and the negative effects
of structural barriers to the use of services. The new methodological approach of
using survey was introduced, which yielded information contradictory to classic
ethnographically obtained data. Findings from these researchers suggested that
Mexican Americans viewed health care as a medically effective positive option
but social and structural barriers prevented their use. These barriers included
the lack of health facilities within the Mexican American communities and the
demeaning nature of the experience with health agencies to Mexican American
patients (Karno & Edgerton 1969; Weaver 1969). The heterogeneity of the
population was finally addressed and socioeconomic status and structural issues
began to be explored as it affected health beliefs and practices (Moustafa &
W eiss 1968). These additional authors rejected the old argument that Mexican
2 8
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Americans did not seek clinical care fo r cultural reasons. Other works integrated
the importance of the effects of cultural phenomena and sociostructural barriers
on health perception and health care use. Kay, a prominent researcher at that
time, demonstrated the importance cultural relevance in health research. Kay
(1977) documented beliefs in folk illness and causation. But, the importance and
people's adherence to traditional beliefs and curing ways were lost among the
younger generations of Mexican Americans in e/ Jardin, where Kay conducted
research. Both service providers and curanderos (folk healers) were sought for
treatment but curanderos were sought when physician treatment was perceived
to fail. Another study by Weaver demonstrated that living in rural areas versus
living in urban ones, limited the population’s access and ability to obtain
physician services (Weaver 1970). Since physicians were difficult to reach
because of geographical barriers, people used curanderos who were more
readily available in their own communities.
Additional research specifically on gender emerged as an attempt to
modify the stereotypes found in the social science literature about Mexican
American women, which often viewed women not in charge of their health or
their lives. For example, Madsen stated that “where he [Latino male] is strong,
she [Latina female] is weak. Where he is aggressive she is submissive” (Madsen
1973:22). The research of Mellville (1980), Manzanedo et al. (1980), and Velez-
lbanez (1980), presented the life-styles o f urban Mexican American women,
avoiding the rural stereotype, and made the structural barriers that prevented
29
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women’s access to the health care system visible and vocal. Melville (1980)
argued that poor educational opportunities lead to poor paying employment and
poor paying employment limits the opportunities for women to gain access to
health care (Melville 1980:3). Manzanedo et al. (1980) called attention to the
lack of participation of Mexican American women in the systems of health,
employment, and education. Manzanedo et al. stated that it has been easy for
agencies to say that Spanish-speaking women would not participate in certain
programs because it was contrary to their cultural norms. Although strides were
made in the participation of Mexican Americans in health a s physicians, nurses,
and other professionals, the fact remained that Mexican Am erican women
appeared [and still do] largely outside the North American health care system
(Manzanedo et al. 1980: 203).
Perhaps one of the most impressive works is that of Velez-lbanez (1980)
related to the non-consenting sterilization of Mexican women in Los Angeles.
Velez-lbanez was called to act as an expert witness on behalf of ten Mexican
women who were suing a group of doctors that sterilized them without their full
consent. The women lost the case because the judge remarked that the “cultural
background of these particular women had contributed to the problem in a subtle
but significant way” (Velez-lbanez 1980:245). Of this Velez-lbanez argued that It
was obvious by the judge’s decision that within a paternalistic institutionalized
behavioral environment, Mexicans have a high probability o f being marginalized.
The medical sterilization and legal judgements, Velez-lbanez contended, upheld
30
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
this fact. The judge legitimized the doctor's actions and his actions against the
women noting that the doctors were too busy to note “cultural differences"
(Velez-lbanez 1980: 248). Even more importantly, the argument o f the judge
was that women were so different that the doctors could not have known the
effects of sterilization unless they had carried out studies similar to the one
Velez-lbanez carried out in the case as an expert witness. The actions that
occurred in this case were within the confines of a system, which controls and
organizes the diversity of culture and the sexuality of women, reflecting a
structural dominance over women who lack power and participation in its political
and economic domains.
Other researchers expanded on the works presented above by
considering the critical factors that collectively will determine the access of
Mexican Americans to the health care system and illuminate the changes that will
contribute to its improvement. These issues include the homogeneity and
heterogeneity of the Latino population (Modiano 1995:75) and the extent to which
socioeconomic status adversely affects the populations' access to health care.
Ginzberg (1991 ) contends that there is very little that we know about the needs of
the diverse Latino population. But that we know enough to understand that
Latinos who have below average educational attainment, skill levels, and income,
are at risk and will remain at risk for preventable diseases until they have
sufficient coverage for health care (Ginzberg 1991: 241).
31
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Modiano (1995) Insists that utilizing community groups and organizations
and helping create strong community bonds could Improve the potential for
success of minority disease control efforts. The development of Interventions
with community participation Is critical to assure their cultural sensitivity and
relevance (Modiano 1995:76).
Chavez et al. (1995) remind us that there are no cultural deficits, but
rather that communication between service providers and patients Is key to
effective interventions. Thus, they emphasize the fact that researchers and
service providers, and patients as well, must become educated about the cultural
specificity of those communities with whom they w ill work. In earlier work,
Chavez et al. (1992) stress an Important Issue: that Indeed the study population
bring with them cultural differences, but if structural obstacles to health care are
not lowered by acquiring private and medical Insurance, for example, the are not
likely to seek preventive care. This emphasizes the need to separate out culture-
specific concepts of disease. Illness, and disability from other factors that affect
health-seeking behaviors. The authors argue that the relationship between work,
accidents, Injuries, and health seeking Is very complex because seeking for
health care Is ver much related to the availability of insurance by the employer.
Their findings have shown the need for analysis based on a political economy
perspective to be more attuned to variation (Chavez et ai. 1992:22).
32
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Similarly, Singer (1990,1995) has noted in his work on critical medical
anthropology that “research must be directed at clarifying the manner, form, and
degree to which macroprocesses are manifested at the microlevel" (1990:182).
Singer further argues that in complex stratified societies struggle shows in
various levels across multiple axes o f oppression (i.e., struggle against racism,
classism, heterosexism) and that understanding of these by service providers
and researchers can bring numerous opportunities for effective interventions for
the prevention of disease (Singer 1995:98).
Decision-Making. Gender, and the Political Economv of Health
Although there is a tendency to continue to approach health issues from a
micro-level of analysis in some research circles (Baer and Bustillo 1998; W eller
et al. 1993), works of a structural orientation appear more often in HIV/AIDS/STD
studies as well as in respect to decision-making regarding contraceptives.
Medical anthropologists have increasingly shifted from studying folk illness in
small rural areas to studying diseases affecting populations in urban settings
from a more complex cultural, social, and gender construction of biomedical
disease concepts and their significance for specific groups (Chavez 1995: 41 ).
This structural and gender perspective is evident in the HIV/AIDS and STDs
research studies of Amaro (1988, 1995); Ferrira-Pinto, Ramos & Shedlin (1996);
Singer (1992); Alegria et al. (1993); Vera et al. (1993); Gomez & Marin (1996);
Ayala et al. (1996); Chavez (1995); and Organista & Organista (1997). In
regards to general structural risk factors related to immigrants, especially migrant
33
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
workers, and AIDS, researchers such as Organista & Organista (1997)
Illuminated the Importance o f Issues like education, language, high mobility,
poverty and bad working conditions.
Similarly, several researchers have explored the mechanisms of economic
need, racism, homelessness, and social displacement as primary components In
decision-making regarding high risk behaviors which Increase the likelihood of
AIDS/STDS (Vera, Alegria, Santos & Burgosi 993; Alegria, Vera & Burgos 1993;
Hubbell, Chavez, MIshra, Magana & Valdezi 995; Ferrelra-Plnto, Ramos, &
Shedlin 1996). In conjunction with the structural Issues emerging In the
literature, there are the concepts of gender and gender roles that are arising
more frequently as Interactive factors affecting the manifestation and process of
such structural Issues. For example, Amaro (1995) noted that as HIV Infection
Increases among women, the marked lack of research on how gender, women’s
social status, and women's roles affect sexual risk behavior and risk-reducing
behaviors becomes Increasingly more Important to address. Gomez & Van Oss
Marin (1996) took up the challenge (at least partially) by Investigating how
cultural gender norms affect sexual behavior that may exacerbate risk of
AIDS/HIV/STDS among Mexican women. For example, the Mexican women In
their sample had a lessened sense of sexual power (I.e., feeling able to request
or enforce condom use with male partners) as compared to Anglo women. Given
these beliefs, the Mexican women tended to expose themselves to greater risk
behavior In their sexual practices with their partners.
34
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Because AIDS and STDs disproportionately affect poor women in the US,
these works suggest that Mexican and Mexican American women are at risk due
to their gender and their social, economic, and political context in which gender is
construed. These studies focus on structural factors, the health care delivery
system and its role in facilitating or inhibiting HIV/AIDS and STD prevention
methods among Mexican Americans. The body o f work on gender and
structural perspectives in AIDS of Mexican American and Mexican immigrant
women is still very limited. These two populations are briefly mentioned in the
literature as part of cross-sectional studies based on ethnicity or gender.
A plethora of work in AIDS and women’s health and the political economy
strongly challenges past theoretical understandings of gender, class, and health
(Sargent and Brettell 1996; Farmer et al. 1996; Singer 1996; Doyal 1995; Sobo
1995; and Finkler 1994). These works focus on the causes and conditions that
affect women’s health from a global perspective including the United States.
These researchers pose the argument that gender, racism, and class are the
most important variables in most diseases and health conditions interfering with
the health of women all over the world. The premise is that gender, ethnicity,
and, class are risk factors for not being well-served in existing medical systems,
and that many structural relationships of power are a key factor affecting illness.
35
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Sargent and Brettell (1996) Include articles in their edited volume on the
political economy of women’s health, examining gender and health policy. The
authors demonstrate how the lack of inclusion of women in clinical trials and in
HIV risk prevention programs among African American women and Latinos in the
US has contributed to their HIV risk. It is o f no surprise that AIDS is
disproportionately affecting poor women of color in the United States.
Along the same lines. Farmer et al. (1996) contend that the appearance of
HIV/AIDS is the best evidence of the gendered political economies o f health
where forces of racism, poverty, and sexism meet. Farmer et al. ground their
critique in social science and medical anthropology to attest that there is a real
and present world AIDS pandemic that affects mostly poor women. In his
ethnographic account. Farmer reflects on the pandemic from the perspective of
poor women. In one of the chapters Farmer presents vignettes o f three women
from the US, Haiti, and India to demonstrate that more and more women are
linked by global economic networks that structure and limit women’s choices.
The status of these women in these different settings, Farmer argues, is
determined by their social circumstances which in turn determines their health.
The daily risks they take are simply necessary chances against the face of death
and sickness (Farmer et al, 1996: 47). Farmer et al. call these circumstances
and patterns structural violence:
Their sickness...is neither nature nor pure individual will that is at fault, but rather
historically given processes and forces that conspire to constrain individual
agency. Structural violence is visited upon on all whose social status denies
them access to the fruits of scientific and sodal advances, [p. 23].
36
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In their framework, structural violence is a set offerees ranging from gender
inequality to poverty structure unequal access to goods and services, placing
poor women at greater risk for contracting HIV. The authors offer compelling
evidence that gender inequality is an important cofactor in the AIDS pandemic.
For example, they examine community-based organizations that provide support
and care for poor women facing HIV. The contrast is striking between the
number o f AIDS programs and organizations devoted to gay men in the United
States and the limited number and resources of such organizations and
programs for and about women as US-Govemment organizations have
underestimated or overlooked poor women (Farmer et al.: 457).
Singer (1996) looks at some of the key social science and clinical
literature on poverty and AIDS to point out the lack of attention paid to the issue
of how income, resources, and power relate to the risk among minorities for HIV.
He argues that the reliance of biological reductionism, and multiple clinical and
social factors act synergistically to affect the health of poor women and men of
color as it relates to HIV. Singer states that:
Among humans, of course, involvement with the environment is socially
determined. For example, class plays no small role in determining
exposure to particular microbes. Thus, to take one jarring example, the
rate of pediatric AIDS among the poor is many times higher than among
the wealthy. Summarizing data on HIV seroprevalence for newborns in
New York City note that the areas of the city with the highest levels of
infection are poor inner-city neighborhoods, where low-income minorities
constitute a substantial portion of the population. These are the same
neighborhoods that have suffered the highest rates of AIDS-related
deaths... as the case of AIDS suggests with sharpening clarity, human
biology, which is affected in each generation by differential survival and
reproduction, is in no small part a product of political economy [p. 504].
37
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Doyal (1995) also argues that the III health o f women is not biologically
determined but that many external obstacles prevent women from meeting their
health needs. These obstacles include global inequalities of income and
opportunity structures and environmental degradation (i.e., local upheavals and
wars). Even though men and women face these problems equally, access to
and distribution of resources for the health of women are limited because these
resources are structured by gender. Doyal’s work shows that women are
additionally burdened with household responsibilities and a continuing epidemic
o f violence in ordinary households. Women face many daily occupational
hazards, low pay. low status, and no political power to solve their problems.
These stresses translate into ill health where sex is no longer safe because
women are often constrained to negotiate what Doyal calls “heterosex” (sex with
men) from a position o f frailty.
Along the issue of “heterosej^, as Doyal contends, Sobo (1995) shows
that AIDS manifests itself not only in the world o f political economies of health,
but also in women's households. Sobo studied women clients in a Maternity
program in the US. She examined African American women's lack of use of
condoms in their heterosexual relationships. Sobo makes some connection
between relationships and household economy, but she tends to see condom
use as a health belief rather than an economic issue. Still, Sobo argues that
women must constantly negotiate a poor, urban, racialized, and gendered world.
38
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
She concludes that women believe that monogamy will protect them against HIV.
The reality is that women idealize monogamy as a protective factor when indeed,
this behavior puts them at greater risk for HIV because sexual fidelity with one
man (who is unfaithful) may be more dangerous than casual sex with condoms.
Finally, Finkler (1994) tells ten life stories of Mexican women, most of them poor,
who suffer from chronic, nonfatal illnesses for long periods. Finkleris strongest
conclusion is that women have agency in spite o f their poverty and that when
they have the means to change and control over their life situations, their health
improves, usually dramatically and creatively.
These authors conclude that if social factors, like race, class, poverty or
HIV fall heavily on men, they affect women and children even more. Sometimes
the biomedical models and methods and new technologies are themselves
sources of new obstacles for women's access to health care (i.e., the lack of
funds to purchase expensive AIDS treatment therapies). With or without these
resources women still have the burden to take care of everyone but themselves.
These arguments have broad implications four our understanding of gender,
class, medicine, disease, and health. They strongly show that gender is the first
divide in access to health followed by class and race; it is class and race that
divide women from each other and then from life itself. These works demonstrate
that the old behavioral and cultural models for understanding the spread of HIV
are inadequate. New models are needed to seriously consider the ways in which
39
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
racism, structural apathy, poverty, and gender Inequality increase the
transmission and inhibit the prevention of HIV/AIDS and STDs.
From 1980 to 1998 studies of decision-making and fam ily planning reveal
that consistent and effective birth control among Mexican American women is not
primarily affected by cultural factors. Instead, services are often inaccessible,
whether it is for economic reasons, or caused by the structural barriers (Urdaneta
1980; Andrade 1980; Cates & Stone, 1992a, 1992b; Frank 1998; and Garro
1998). Urdaneta (1980), for example, discovered that it was the economics and
bureaucracy that were the hindrances preventing women to make decisions
about their use o f fertility regulations instead of traditional cultural patterns
(Urdaneta 1980; 33-35). Urdaneta gathered data from Mexican American
women in family clinics suggesting that Mexican American women-regardless of
apparent resistance to fertility regulation attributed to Mexican culture-are eager
to regulate their fertility when the regime to be followed is presented in a
culturally sensitive manner and is consonant with their economic reality.
Urdaneta concluded that modern effective contraceptives in the United States
are a “middle-class commodity” and that poor women make decisions about the
adoption of contraceptives based on their economic viability and the accessibility
of low-cost programs offered through inconsistent government funding (Urdaneta
1980: 34).
40
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Similarly, Andrade (1980) called for a need to develop new theoretical
frameworks that avoid the over-linking of cultural factors to the use of
contraceptives. Andrade instead focused on sex role and socio-economic factors
as investigative issues in the study o f health among Mexican Americans
(Andrade 1980:33). Andrade used a path analysis statistical model to survey
150 Mexican American female students regarding their identification with
traditional Mexican American culture in relation to their attitudes about fam ily
planning and decision-making. In general, Andrade’s findings did not support the
assumption that cultural identification is a factor affecting the women’s' attitudes
and their decision-making related to fam ily planning. Andrade found no evidence
whatsoever relating the measures o f cultural identification to the women’s actual
decisions to use of contraceptives in spite of the stereotypes of passivity, sexual
ignorance, and virginity that existed with reference to Mexican American and
Mexican women in some of the scientific literature (Andrade 1980:29).
Andrade’s finding provokes a more careful examination of the role of
culture in decision-making because economic considerations related to fam ily
planning and decision-making (i.e., overpopulation, expense or large fam ily),
were the major attitudinal factors influencing women’s decisions to use
contraceptives. Andrade’s work began to address the issue that there is a
shortage of accurate, comprehensive, regional demographic data on how
Mexican American women make decisions about family planning because most
the conclusions about Mexican American women’s practice of contraceptives
41
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
have been drawn from rural populations. The relevant Information currently
available about Mexican and Mexican American women and declslon-maklng
related to HIV/STD and pregnancy still needs to be Initiated.
Another related Issue Is that personal decisions about health are not
entirely up to the Individual In some cultures and do not necessarily match those
of service providers. Frank (1998) argues that personal decisions about health
vary among cultural groups and their preferences In declslon-maklng styles not
always agree with those of North American clinicians. Frank challenges
clinicians to find a better fit to address the diversity In declslon-maklng styles of
the patients they serve. She states that “approaches to Individual declslon-
maklng that do not take [cultural] relationships Into account are Inadequate”
(Frank et al. 1998: 404).
Declslon-maklng has been also noted by other researchers who argue
that studies of declslon-maklng divert attention from the Influence not only from
divergent cultural models, as Frank suggests, but also from Influence of the
broader political economy when considering choice. Garro (1998) for example,
has found that formal declslon-maklng models are Insufficient for representing
sickness because these models are biased and vary from the practices of the
subject’s Interpretation of Illness. Garro contends that “these models have little
to neither do nor are they sensitive to Intercultural variation In people’s
conceptualization of Illness" (Garro 1998: 320). How health and theories reason,
stem from divergent rationality while these are Implemented with various
42
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
cultures. Garro holds the view that human cognition that is grounded in a social
and cultural process has been ignored. This is not to negate that the decision
making view is irrelevant because it does not touch on macro-level factors.
Rather, in some cultures decisions are not truly personal or voluntary and must
be understood in relation to the cultural, political, and economic context in which
people operate.
Furthermore, decision making-models related to HIV/STD and pregnancy
prevention have not adequately explained how women at-risk adopt decisions
about prevention. The context in which these women make daily decisions about
preventing HIV or pregnancy exerts a strong influence on both its process and
outcome. The most succinct expression of this strategy, that is, both
contraceptives and HIV/STD prevention, comes from an extensive two part
review of similarities and differences in the field of contraceptive and HIV/STD
prevention authored by Cates & Stone (1992a, 1992b). Their review expresses
concern over the lack of integration in the two fields and concludes that over the
next decade, one of the most important areas of research will be a demonstration
project to evaluate the integration o f STD and family planning programs. This
initiative is an opportunity to integrate research of how decision-making related to
preventing HIV/STDs and pregnancy is practiced and how they are similar and
different since condoms are used both for disease prevention and pregnancy.
W ithout current evaluation of both situations, the decision-making process that
leads to condom use for both purposes and in relation to the cultural and social
43
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
context will go unnoticed. Attention to this issue is caicial because numerous
studies have concluded that condoms, spermicides, and mechanical methods
combined with spermicides all provide protection against HIV/STDs and
pregnancy (Cates & Stone 1992:152). Yet, most publicly supported fam ily
planning and HIV/STD clinics are not integrated entities. Women who receive
services in fam ily planning not always are given HIV/STD prevention information
because these services are offered in physically separated sites under different
eligibility criteria. Thus, this poses a structural barrier, because it is difficult for
women to access these services all at once (Cates & Stone, 1992: 157).
Mexican Immigrants in Los Angeles
In 1990, there were 8.7 million residents in Los Angeles County, of these
approximately 41.4% were Anglos, 37.9% Latinos, 10.3% Blacks, and .9%
Asian/Pacific Islanders. In 1990, of the 3.306 million Latinos residing in Los
Angeles County, 2.5 million were o f Mexican origin (Hayes-Bautista 1992: 11).
According to Hayes-Bautista, even if immigration were to cease immediately and
completely. Latinos would still be the largest population group by the year 2000.
Both high birth rates and in-migration have fueled the increase in the Latino
population growth. The growth over the past two decades is the legacy o f nearly
five hundred years of demographic change experienced by Mexico and Latin
America. Los Angeles lies at a migration path that has been trod for centuries,
irrespective o f changing national borders or immigration control (Hayes-Bautista
1992:1 ). W ith the rise of immigration, the Latino population has become
44
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
increasingly complex and composed of foreign- bom Latinos. Among adults
living in predominantly Latino census tracts, 62% are immigrants. The great
m ajority o f immigrants residing in Los Angeles are of Mexican origin (Hayes-
Bautista 1992; 11).
In spite of the high number of Mexican immigrants residing in Los
Angeles, very little is known about them in terms of gender-related decision
making about HIV/STD prevention and adoption of contraceptives. Although
there is research related to HIV/AIDS on Mexican immigrants in general in
California by anthropologists and other researchers (Magana 1991; Magana and
C arrier 1991; Carrier and Magana 1991; Bronfman and M orenol 996; Chavez
1992, 1994, 1996; Giocoechea-Balbona 1994; Mishra et al. 1996; and Organista
and Organista 1997), there is a relative scarcity of research in the Los Angeles
area and, specifically, on Mexican immigrant women concerning this topic.
As noted by Mishra, et al. (1996) in their book AIDS Crossing Borders
there is substantial research conducted on immigrant and migrant worker
populations on the W est Coast, in general, but little is known about these
populations, and especially in terms of specific large urban areas such as Los
Angeles, due to several methodological problems. These methodological
problems include migratory patterns, availability of sex partners and identification
of sex practices, which may be greatly affected by geographic location.
However, some researchers have engaged the question of immigrants, with
45
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
attention to gender issues, and urban locations. For example, Magana and
Carrier (1991) conducted their research in Orange County, California, focusing
prim arily on HIV/AIDS and Mexican immigrant men and drug-addicted sex
workers. Their results were pivotal in understanding a major vehicle of
HIV/STDS transmission—specifically that the men were becoming infected by
way o f contact with other men’s semen w ithin the sex worker’s genitals.
Another example of investigations that have attempted to focus on the
issue of immigration and its effects— however, again, not based in an urban
area— is the work of Bronfman and Moreno (1996). In their cross-border
ethnographic analysis of migration from the town of Gomez Farias, Mexico to
W atsonville, California, they verified the relationship between migration and the
risk o f getting AIDS. They brought to the forefront the idea that among the
immigrating population, there was an increase in HIV/STDS risk practices which
were associated with such issues as migration to a much more “sexually open”
society, economic limitations (i.e., access to prophylactics), and lack of education
regarding HIV/STDS. Interestingly, Bronfman and Moreno, make mention of (but
do not develop) the ideas that women experience themselves as having little
power of decision over sexual practices and that condom use increases among
the men with increased time in the U.S. In effect, the above studies illustrate
how past research has predominantly focused primarily on men or other
geographical areas of California that do not include Los Angeles County. This
means that very little is known about specific factors affecting these populations
46
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
in Los Angeles County. It should be specified that there has been AIDS/HIV
research done in the area of Los Angeles. Indeed, there have been significant
contributions in terms of women’s issues and AIDS (Moe, McGee-Smith,
Dematis, & W yatt 1998; Wyatt, Srinivasan, Axelrod, Tucker, Romero, & Mitchell-
Keman 1996; Arguelles, Rivero & Reback 1989, Mays & Cochran 1988) and also
general ethnic comparative studies centered on the epidemiology and risk
behaviors between groups (Marks, Cantero, & Simon11998). However, none of
these studies have focused particularly on Mexican immigrant women. Thus,
making the need to focus research on this population beneficial in the efforts to
expand the domain of anthropological understanding of AIDS/HIV among urban
minorities.
Challenges in Immigrant Health Research.
The study of Mexican immigrant health issues in Los Angeles requires a
more in-depth exploration of immigration processes, given that this population is
affected by sociostructural factors. These sociostructural factors include the lack
of health insurance, high incidence of HIV/AIDS in Los Angeles, poverty, and
methodological barriers that interfere with these populations access to health
care. A large number of Mexican immigrants work at low-wage jobs and thus
are a great risk of diseases such as HIV/AIDS (Cornelius 1984; Ginzberg 1991;
and Chavez et al. 1992). The existing approaches to the study o f the health of
Mexican immigrants are limited in scope. For example, the study o f immigration
is often seen as a labor migration, and thus emphasis on the health of Mexicans
47
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
has been in the form o f studies on US-bom Mexicans Americans and not
Mexican immigrants. Therefore, most research studies and social policies have
been based on the Chicano/Mexican American experience rather than on those
o f Mexican immigrants in the US.
Theories on Mexican immigration vary; some are from the structuralist
"push-pull" perspective that see Mexican immigration occurring in the context o f a
capitalist-dependent labor demand from the United States (Elac 1961 ;
Bustamante 1981; Cornelius 1983). Others are from a culturalist model of
Mexican immigration originating from the work of Gamio (1930, 1931) who saw
immigration as a matter of an individual choice rather than as a more complex
structural issue. Kemper (1979) and Uzzel (1976) have been critical of the
culturalist approach because it rests on a micro-level analysis that denies the
macro-level examination these issues require. These theories are limited
because immigration does not happen in a vacuum. Immigration is very much
influenced by social, economic, and political factors (Portes 1978, 1996; Wood
1982; Tienda 1983; Sassen 1988; Guidi 1993; Borjas 1996; and Kennedy 1996).
Therefore a micro and macro level approach is needed to accurately represent
immigration. Research on the health of immigrants, in particular, poses
methodological difficulties and relatively little has been done in this area. Most of
the research has been done on Latinos In general, often mentioning Mexican
Immigrants sporadically. Demographic characteristics and ethnic definitions are
difficult to establish because most social scientists do not agree on these issues.
48
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
especially on the definition o f the terms “Latino/Hispanicf, and “health and health
use” (Modiano 1995: 75). Morbidity and mortality data do not represent sub
populations of ethnic Latino immigrant groups living in Los Angeles County. For
example, the County epidemiologists group statistics under the term “Hispanicf
but specific ethnic groups are not differentiated. So, it is difficult to differentiate
immigrants of Mexican origin from other Hispanics.
Another bias occurs in the data of health care utilization because most of
the HIV/AIDS statistics are collected on patients utilizing services in public
settings. Very little is known about the number of Mexican immigrants who
actually utilize public health services versus those on the private sector. Another
challenge in researching the health of Mexican immigrants is that Mexican
communities and those agencies that provide services fo r them view researchers
with reservation, making collaboration between scientists and communities more
difficult to attain (Altman 1995; Gomez et al.1998). This distrust seriously affects
the reliability and validity of the data, especially when the studies are related to
undocumented immigrants. In the case of researching Mexican sex workers in
cantinas, the greatest difficulty lies in gaining access to respondents because sex
work is illegal in California. Women were distrustful for fear of facing an
undercover agent from the “plaça” (police) or “la migra" (the Immigration and
Naturalization Service, INS). To respond to these challenges, it is important for
researchers to begin to conduct holistic studies on the diverse ethnic and
immigrant sub-groups in Los Angeles. Of equal importance is the participation of
49
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
researchers in the study of immigrants who are culturally competent and/or
culturally and linguistically representative of these populations, or who,
regardless o f their cultural representation, have a constituted rapport with these
study populations.
The Health Conditions of Immigrants in Los Angeles
The data on the incidence, morbidity, and mortality from AIDS, cancer,
and other diseases affecting Latinos or Latino immigrants in Los Angeles is
scattered, outdated, and often fragmented. From the review of the literature,
there is no clear picture of the health o f Latino immigrants in general or that of
Mexican immigrants living in Los Angeles. Few studies have focused on the
health of Latinos and Mexican immigrants in Los Angeles (Hayes-Bautista 1992;
Hayes-Bautista et al. 1994; and Valdez et al. 1993). The work o f Hayes-Bautista
et al. (1992, 1994) and Valdez et al. (1993) has attested that Latinos in general
are a healthy population but that their lack o f access to health care, not their
culture, places them at risk for preventable diseases. The major health threats
fo r Latinos, these researchers argue, are communicable diseases, lack of health
insurance, and lack of access to health providers and facilities
Hayes-Bautista et al. (1994) draw their conclusions through studies of the
health of the Latinos in California from 1985-1990. Hayes-Bautista et al. relied
on demographic and medical records to prove that Latinos, in spite of their low
socioeconomic status, demonstrate a long life expectancy, healthy children, and.
50
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
for females, a very low rate of smoking, drinking and substance abuse. Hayes-
Bautista portrays Latinos as a healthy population living in unhealthy
environments (Hayes-Bautista 1994; 593). For example, they argue that Latinos,
and immigrants in particular, bring with them a strong fam ily structure that acts as
a protective factor. However, this very positive trait is under constant siege,
obstructed and frustrated by major environmental obstacles to the development
o f their fullest economic production and capacity. These obstacles are present in
housing policies that weaken fam ily structure, fundamentally unhealthy
environments for working and living, and a political system that ignores the
participation of Latinos in the economic future of Los Angeles. These obstacles
are weaknesses between Latinos and the structures that operate the city but not
the result of some fatal flaw inherent within Latino culture (Hayes-Bautista 1992,
1994).
According to Valdez et al. (1993), approximately 35-37 million Americans
are uninsured; Latinos account for a disproportionate share of the total,
numbering approximately 7 million. The real problem is that important issues
related to this lack of health insurance, such as the structural and institutional
barriers that specifically affect Latino communities and the ability of their
members to secure their health are ignored by health policy. Valdez et al. attest
that:
Latinos live in regions of Los Angeles County where
assuring clean water is as important as acquiring medical
care. They live in areas where transportation can be as
critical as affordable services. Usually these are
51
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
communities where violence rather than a virus produces
the major health risk; and districts with working conditions
and economic opportunities that overshadow the ability of
medical care to maintain health. Ensuring clean water,
decreased violence, and healthful working conditions are
public tasks that cannot be ignored in Latino communities
as health care reform debates shift the focus to concerns
about financing health care (Valdez et al. 1993:1 ).
Like Hayes-Bautista et al. and Valdez et al., Vega et al. (1998),
researchers who have conducted studies on Mexicans and Mexican Americans,
argue along the same lines. In their study of Mexican immigrants and mental
health, Vega et al. argue that “despite low education and income levels, Mexican
immigrants had lower rates o f lifetime psychiatric disorders compared with rates
fo r the US population as a whole. Psychiatric morbidity among Mexican
Americans, is primarily influenced by cultural variance [this is an issue of
culturalism because it refers to acculturation level] rather than socioeconomic
status or urban versus rural residence” (Vega et al. 1998: 771-772). Their major
finding, that place of birth had a more significant influence on the prevalence of
mental disorders than traditional demographic factors such income or
educational level, challenges the belief about the positive effects o f
“Americanization” or acculturation (Odegard 1946: 382-383). This means that
assimilation into American culture can have adverse health effects because there
is a breakdown in cultural protective factors such as the loss of fam ily ties, fewer
social networks, and higher exposure to drugs as a coping mechanism. Vega et
al. (1998:773) point out the health and psychological risks engendered by
immigration from Mexico to the US:
52
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Mexican immigrants share the lower risk status of their national origin, but
acculturation has deleterious effects on many aspects of their health at the
population level. The association between length of residence and
psychiatric disorder among immigrants provokes important research
questions. W hy does socialization into American culture and society
increase susceptibility to psychiatric disorders so markedly? W hat
components of Mexican culture are protective against mental health
problems, and can these be conserved? [p. 774]
Other researchers have reported sim ilar results of lower acculturation level
being associated with better health outcomes. For example, Zembrana et al.
(1997) found that Mexican Immigrant women showed more desirable prenatal
behaviors and less risk factors than did the Mexican-American women in her
sample. However there was no significant difference between the groups in
terms of gestational age or birth weight. Escobar’s (1998) research indicated
that drug use was four times as high among people of Mexican descent bom in
the United States than among immigrants (Escobar 1998:782). Given such
findings, it would seem that US life style (i.e., value systems, beliefs, tolerance,
etc,) poses more risks for immigrants because, according to Vega et al. and
others, the longer immigrants have been in the US, the higher their prevalence of
mental disorders and other health problems such as drug use. In general the
above studies demonstrate that cross-cultural research can be pivotal in
advancing our knowledge of risk and protective factors.
The work of Hayes-Bautista et al. (1992, 1994), Valdez et al. (1993), and
Vega et al. (1998), however, pose some problematic and methodological
questions. Their work attests that cultural variance rather than socioeconomic
53
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
status influences the health of Latinos. Since there are no definite or
comprehensive census data, Hayes- Bautista relies on county health data, state
health data, and small area studies to make these conclusions. This is
problematic because factors affecting the health of Mexican immigrant Latinos
and Latinas are unknown because the data are often fragmented or non-existing.
Vega et al. acknowledge that more research is needed to be fully confident about
the validity his study. About this they state:
Culture and linguistic issues abound. A series of
international studies are underway to address various
validity and reliability issues, including whether diagnostic
interviews with Hispanics or other ethnic groups are
biased toward or away from specific diagnostic criteria, or
whether English or Spanish language use created
differential response patterns, both of which could
influence accurate case ascertainment [p. 780)].
The question is: How can one explain that in spite of poverty and the lack
of access to health care among Latinos, they are still a fairly healthy population?
That is, the prevalence rates for disease remain low fo r immigrants despite
external factors such as those named above. Researchers have failed to answer
this question with clarity and completeness. Nevertheless, researchers such as
Hayes-Bautista et al., Valdez et al., and Vega et al., acknowledge, at some level,
that Latinos have internal structures that helps them cope with barriers posed by
poverty and the lack of access to health care. These explanations romanticize
the cultural values of Latinos and fail to draw a strong and concise relationship
between race and poverty, class and gender, and power and powerlessness.
54
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Nevertheless, Hayes-Bautista et al. and Valdez et al. insist that real
threats to the health of Latinos are communicable diseases and the lack of health
insurance. Hayes-Bautista estimated that there were 2.2 million uninsured
persons living in Los Angeles County. O f these, there are 1.3 million Latinos
without health insurance, and within the Latino population there is an unmet need
of one to three million doctor visits for basic health care. This lack o f coverage is
worse among the immigrant Latino population (Hayes-Bautista 1992: 73).
Hurtado et al. (1992) showed that in the immigrant generation only thirty nine
percent of female and fifty four percent of male heads of household had
insurance coverage. By the third generation, seventy four percent o f female and
eighty two percent of male’s heads of households had health insurance
coverage. It would be reasonable to assume that the more heavily immigrant
areas are the ones most lacking adequate health insurance coverage, thus,
resulting in more health problems.
To complicate matters. Latino areas are grossly underserved and
characterized by Hayes-Bautista as “ a level of service availability seen only in
the poorest of the third world countries” (Hayes-Bautista 1992: 73). The advent
of managed care will inhibit access to health care for the immigrant Latino
population in Los Angeles County. This is due to the fact that immigrant Latinos
rely heavily on the Los Angeles County/USC General Hospital emergency rooms
for outpatient health care. The county recently downsized its general hospital
bed occupancy, shifting most o f its health care provision to managed care
55
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
providers or community clinics fo r outpatient care. These clinics are barely
surviving as a result of the managed care contract restrictions. W ithout these
community clinics as service providers to the poor and uninsured, Mexican Latino
immigrants face less access to health care in the future; an issue rarely explored
by researchers.
Mexican Immigrant Labor in Los Angeles
Mexican immigrants, and especially Mexican undocumented immigrants,
typically work in low-paying jobs with few benefits such as medical insurance
(Valdez et al. 1993; Ginzburg 1991). Undocumented immigrants tend to fit in
jobs in either the secondary or informal sector of the job market. Secondary
sector jobs are those that offer low wages, no job security, and no benefits. This
corresponds well to the structure of the US market and the temporary nature of
many Mexican immigrants (Priore 1979). Some researchers have argued that
this is a result of the economically dominant position of the US with respect to a
less powerful Mexico (Portes 1978, 1996; Wood 1982; and Sassen 1988;
Kennedy 1996; and Rumbaut 1996). The informal sector, on the other hand,
offers Mexican immigrants jobs in small firm s and self-employment. But those
employees who work either in the secondary or informal sector often do not
receive any form o f health insurance benefits.
To understand the political and economic ramifications of how Mexican
immigrants fit into the labor market in Los Angeles, it is important to take a
historical look at Mexico’s relationship with the United States in terms o f trade.
56
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Mexico is in a continual economic restructuring with the US. An example of this
is the changes that took place with the entry of Mexico into the General
Agreements on Trade and T ariff and NAFTA in 1987. Los Angeles has become
the lead region of much of this trade because of the 6 million Latinos who work
and produce in this region. However, Latinos, and especially undocumented
immigrants, are the majority o f the workforce but poorly utilized and organized
within the labor structure in Los Angeles.
According to Hayes-Bautista, in 1990, Latinos were the greatest entrants
into the workforce growing 56.2% from 1980 to 1990, with Latino males the most
likely to participate in the labor force. In Los Angeles County, 81.7% of Latino
males participated in the labor force compared to 74.5% of the non-Latino male
population, including Anglos (Hayes-Bautista 1992: 30). Of all o f those who
work, most of them work in the private sector, and are less likely to work in the
public sector or government jobs. US-born Latinos on average have more
education than immigrant Latinos. This means that US-born Latinos tend to be
represented more in professional, white-collar occupations than immigrant
Latinos. Immigrant Latinos encounter language barriers due to their lack of
education and their undocumented status. This affects entry into certain types of
jobs in corporate settings. For example, it is common knowledge in Los Angeles
that there exists an unknown but significant number of immigrant Latino
professionals working in low-skilled jobs or self-employed as professionals.
These professionals who are often physicians, lawyers, dentists, and others.
57
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
cannot practice their professions because they are not licensed to practice in the
US. Some practice without a license with the risk o f being arrested (Hayes-
Bautista 1992; 30). This human capital is usually underutilized. For the most
part these immigrant professionals, along with those who lack an education,
bring skills into the workforce including: brick laying, plumbing, furniture making,
construction, gardening, food production service, among others. Thus, Latino
immigrants bring a source of potential economic strength into the work force
(Hayes-Bautista 1992:31).
It is obvious that Latinos are underutilized in the work force as very few
occupy positions in professional or technical jobs where they can be trained or
promoted (Hayes-Bautista 1992: 40). Most Latino immigrants are over-utilized in
menial labor in non-permanent employment. One has only to visit the Day
Laborer Centers and street corners in Los Angeles County where thousands of
Latino day laborers, mostly Mexican, congregate to seek day labor. The jobs
offered to them are often as gardeners or construction workers with a typical
duration of one day to perhaps a month, if they are fortunate.
Women are also underutilized in the workforce in Los Angeles County,
and historically have had a lower labor force participation rate than males. In
1992, in the County as a whole, all females have a participation rate in the mid
50% range, about 20-30% lower than males. Unlike males, Latinas have the
58
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
lowest labor force participation rates at 9S.3% followed by Anglo women at 57%
and African American and Asian Pacific Islanders females who have the highest
at 58.7% (Hayes-Bautista 1992: 41). W hat employment options are there then
fo r Latina women? Is it surprising to find that some immigrant Latina women are
ending up in sex work as a last resort? How do the attitudes of those controlling
the job market inhibit Latina immigrant women from participating in desirable
jobs? Clearly, they are often shunned and declared “non-productive."
These are difficult questions to answer, since there are no system atic
studies examining the employment patterns of immigrant Latinas in Los Angeles
County. However, it is common knowledge that most immigrant Latina women
work in secondary and informal sectors as housekeepers in the hotel industry,
seamstresses in the garment industry, domestic workers in private homes, or
lastly sex workers in cantina settings. Based on my observations, the attitude of
employers in the labor force towards immigrant Latina women have been
negative. Immigrant Latina women are not invested in, but instead are shunted
aside and declared unproductive. They are usually not enrolled in apprenticeship
and other skills-development programs, and their search for jobs is not facilitated
by public or private efforts. The jobs they occupy do not offer appropriate wages,
health insurance, benefits, or upward mobility or job security. Most o f the
welfare-to-work initiatives are tailored to English-speaking, documented Latinas
who have traditionally been on welfare. In contrast, unfeasible immigration
59
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
policies seriously affect the job opporiunities and occupational mobility of the
undocumented as well as of those perceived as undocumented.
Women and Sex Work
Much o f the literature on prostitution and sexually transmitted diseases
(STDs) portrays sex workers as the agents of disease transmission and does not
address the intimate lives of these women or those of their customers. Most of
the epidemiological literature explores the biological factors through quantitative
methods rather in light of than cultural factors through qualitative methods or a
combination of the two. How prostitution serves as a means of women’s
economic survival and the social aspects of sexually transmitted diseases
involves a wide variety of relationships. This tends to disguise the nature of the
work. In a discussion of prostitution worldwide, Day wrote that in some societies
there was “difficulty in labeling prostitutes and distinguishing them from “wives”
and “friends” (Day 1988:421 ).
According to the literature, the exchange for money among sex workers is
not the rule as often women exchange sex for food, lodging or other goods
(Ferreira-Pinto et al. 1996:124-127). I cannot really offer a history of prostitution
in the study site because no data exist on the subject. Various researchers such
as Oscar Lewis (1966), Deren et al. (1997), Bronfman & Moreno (1996), Ferreira-
Pinto, Ramos, & Shedling (1996), Magana et al. (1996), Perez & Fenelly (1996)
and Mishra & Connor (1996) have studied sex workers in Mexico and the U.S.
60
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
but not on site or in cantina settings. However, all researchers mentioned
economic need, lack of access to occupational mobility, and lack of jobs that
provide a steady income, as the causative factors for a life style in sex work.
The Nature of HIV/AIDS. STDs and Sex Workers
The incidence of HIV/AIDS and STDs in the U.S. and in the world has
triggered the attention of public health officials to focus on sex workers as vectors
of these sexually transmitted diseases, and target these women in HIV
prevention programs. Sex workers are well represented in studies about HIV
and condom use; the men who buy sex from them a re seldom studied (Campbell
1990, 1991,1995; Heart 1996:139). This perspective assumes that it is the
female sex workers who are infecting these men, when in fact, women are more
likely to get infected from men (Radian et al. 1991:26S). In Los Angeles County,
for example, Latina women are one of the groups m ost at risk for contracting the
HIV virus through heterosexual contact. The HIV rates among Latina women
have risen steadily since 1995, showing a sharp upward trend (Los Angeles
County HIV Prevention Planning Committee 1996:33-41).
Since the AIDS epidemic began, much of the literature has been the result
of epidemiological studies on HIV transmission. This interest is understandable
since public health officials are concerned with decreasing the spread of HIV.
61
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Although there are limited data on sex workers in Los Angeles County, HIV and
other STDs have resulted in Increased attention on sex workers rather than on
the men who buy sex from them (Los Angeles County HIV Prevention Planning
Committee 1996:182-183). Of this, Gagnon stated that “much of the research
that has been undertaken Is examining sexuality from the perspective o f AIDS
rather than AIDS In the perspective of sexuality." (Gagnon, 1988). Thus, sex
work Is Investigated because of AIDS, not because of the meaning and context of
sexual behavior In relation to the whole population. Condom use Is reported to
be rare among sex workers, and the Latino men who buy sex from them
(Bronfman & Moreno 1996:56). Therefore, transmission of sexually transmitted
disease from female sex workers to male clients Is Implied. For example, a 1992
study among male farm v/orkers In Florida Included having sex with female sex
workers as a risk factor for the male customers (Centers for Disease Control
1992: 723-725).
Other studies portray clients of sex workers at high risk of HIV Infection
because they have had sexual contact with female sex workers (Plot et al. 1984;
Redfleld et al. 1985). Clients of these sex workers have not been researched
(Day 1988, 1993; Darrow 1990). An epidemiological study of HIV Infection In
Tijuana, Mexico, for example, examined the rate of Infection among female sex
workers who were seen as an HIV risk for the male customers (Guerena-
Burgueno 1991:623-625). In this study, the men who frequented the sex workers
were not studied. Another study by Mishra et al. (1996) refers to the
62
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
seroprevalence in sex workers as an “indirect method to estimate both the
potentials of HIV transmission and its prevalence among male farm workers.”
(Mishra et al. 1996: 16). These studies and several others on HIV transmission
exclude a large portion of individuals within society, who regularly engage in
sexual activity whether with sex workers or others.
The implication is that early in the epidemic, AIDS and STDs were seen
and still are to some extent, a disease of prostitutes and drug users by
researchers. Another implication is that much of the early concern about the role
of sex workers in the heterosexual spread of AIDS in the United States has been
based on surveillance data from men who reported contact with sex workers.
The reliability of this data was questioned because men did not admit to having
sex with other men or injecting drugs (Potterat et al. 1986; Polk 1985). Some
studies, however, show the sex workers do not pose a threat to their customers.
Studies in Mexico, fo r example, have reported a low seroprevalence rate of HIV
among registered sex workers in Tijuana. Registered sex workers in Tijuana
have to undergo periodic health screening and testing for STDs and HIV (Mishra
et al. 1996). Studies in Nevada have shown no known cases of HIV transmission
at the Nevada brothels (Deren, 1997: 203). Sex workers working in the brothels
are licensed by the state and undergo periodic health screening. Rules requiring
safe sex practices are strictly enforced in the brothels (Campbell 1991: 1367-
1378). Because not enough data exists on heterosexual men who have sex with
sex workers, this topic remains a under considerable discussion (Perkins 1985;
63
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Hobson, 1987; Fumento 1990; Campbell 1990). However, researchers must
begin to study sex workers within the context of their fam ily life and the lives of
their male customers, as well as focusing on the range of sexual behavior within
a particular cultural milieu.
Women. Migration, and Famffv Life
The face and the conditions of Mexican women’s immigration is changing
their family life and affecting their health (Melvile 1980; Andrade 1982; Estrada
1987; Carrillo & Hernandez 1988; Gastelum 1991; Chavira-Prado 1992; Salgado
de Snyder 1994, 1997). There is a need to further examine Mexican immigrant
women’s roles outside the context of their family and their native country, and
their role in the labor force and in the family’s migration and adaptation to the
host community. Until recently, the focus on labor migration has been on men
with little attention to women’s roles in labor and migration. A review of the
literature indicates that more women are migrating alone to the US from Mexico
in search of economic opportunities. The sociodemographic profiles of
immigrants to the United States has changed radically, mostly because of the
political and economic changes suffered in Mexico during the last decade.
Changes in the profile of immigrants in the 1990s include a significant increase in
women migrants (Salgado de Snyder 1994:115). Although some studies have
approximated the number and demographics of Mexican women who migrate to
the United States, the data on the number and the profile of this population are
still inaccurate (Carrillo & Hernandez 1988; Estrada 1987; Gastelum 1991 ).
64
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
W hile the body of knowledge addressing the social, cultural and
demographic characteristics of Mexican immigrants continues to expand, these
studies neglect the health of women, their participation in sex work, and their role
in migration. Gastelum, for example, concluded that women do not travel to the
US alone, but rather are accompanied by males. However, Salgado de Snyder
argues that there are an increasing number o f women who cross the US border
alone in search of work opportunities (Salgado de Snyder 1994:118). Women’s
roles have shifted to head of household, having to take on more responsibilities
traditionally left to males whether they remain in Mexico or move to the US. If
they stay behind, they must take leadership of their household at home, and if
they go alone they must make way for others to follow them, a role traditionally
taken by males. If single and migrating to the US, they must take charge of their
destinies by seeking new ways to earn money and improve their lives. However,
once in the US, women have fewer job opportunities, fewer social networks, and
their labor in general is devalued. This challenges the romanticized portrayal of a
Mexican fam ily structure with strong bonds and social networks and Mexican
women following their husbands to the US (Gastelum 1991 )).
The lives of the Mexican women who migrate are often filled with
resilience and hope as well as poverty, loneliness and worry about their children
left behind. Women in these situations often have fear of deportation, frustration
about their new roles as head of households, frustration while shifting from a
65
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
collective fam ily structure to an individualistic one, and a stressful sense of
disconnection from their families. One of the very first studies to address the
mental health of women who migrate was the work of Melville (1980). Although
this study was conducted in Texas on a very small survey sample o f forty-six
Mexican immigrant women, it provided important information about the fam ily
lives and the health of Mexican immigrant women. Melville reported that women
suffered from stress resulting from the immigration process and loneliness
caused from being apart from family, friends and familiar cultural surroundings.
M elville also reported that their lives were often stressed due to situations related
to medical emergencies and giving birth.
Studies of Salgado de Snyder found similar characteristics as those of
M elville (Salgado de Snyder 1994). The Mexican women interviewed by
Salgado de Snyder experienced isolation from their families, worried about their
children, lack of support networks, lack of money, difficulty adapting to the new
life in the United States, and fear of discrimination. Hopefully, the chapters that
follow in this work will offer a greater understanding of the gender roles and the
health of Mexican immigrant women.
The Bidirectional Model as Practice
A common theme in the literature review of the study population is that
medical anthropologists are confronted by a need to choose among evolving
research paradigms and models of practice. Culture remains as a backdrop, but
6 6
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
it shares the stage with a greater awareness of competing variations in the goals
and practicality of research. Speaking to these and related issues to AIDS
research among hidden and marginalized populations, is a bi-directional model of
health education as a method o f practice (Magana et al. 1996).
The bi-directional model is an approach in which health care providers,
community leaders, and patients work in a partnership to solve health problems.
It is a community organization approach that views health in the broader context
of social and economic improvement and views empowerment of patients as vital
to improvement in health status. Better health, in large part, is seen as the result
of improvements in social and educational levels and it involves improved quality
of life as well as access to medical and preventive services. Community
members are encouraged to take greater responsibility for and control of their
own health care while community cooperation is emphasized.
The work of Freire (1970) forms the foundation for this approach. Other
contributors to this literature and approach include Shwebbel (1973), Nix (1976),
Duhl (1986), Biddle & Biddle (1985), Bracht (1988), and Rifkin (1988). In relation
to the literature of Latinos/Mexican Immigrants and HIV/AIDS, advocates of this
model also include Bracho de Carpio et al. (1990, 1998) and Magana et al.
(1992,1996). However, due to the length constraints of this paper, I will only
discuss the work of Freire (1970) to develop a bi-directional model based on his
theoretical concepts. Freire (1970) emphasized direct citizen participation in the
67
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
community analysis praxis (action) and encouraged a “bottom-up" decision
making process rather than a “top-down" health planning approach, where
“experts" determine the community health promotion agenda and new initiatives.
Freire argued that within a system (i.e., economic, educational, m edical) a
person finds two dimensions: reflection and action or praxis (F reire 1970: 75).
According to Freire, there is no transformation without action; people are not built
in silence but in action-reflection. W ithout action and reflection there is no
dialogue, without dialogue, there is no communication. And w ithout
communication there can be no true education. Dialogue must be bi-directional,
where education, which is able to resolve the contradiction between teachers and
students, takes place in a situation in which both (teacher-student) address their
act of cognition to the object by which they are mediated (Freire 1970:81 ). Thus,
the dialogical character of education as the practice of freedom does not begin
when the teacher-student meet in a pedagogical situation, but rather, the former
asks himself/herself what he/she will dialogue with the latter about (Freire 1970).
Moreover, Freire asserted that humans were subjects, independent beings
who had agency and able to transcend and recreate the world. H e thought of
consciousness as determined by the socio-economic and political context, and
also by cultural conditioning through one’s upbringing, education, and religion; an
inter-change between economic and cultural structures. Using Freire's
framework, I argue for a bi-directional model to explain the relationship between
6 8
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
culture and socio-structural forces affecting the health of sex workers and their
customers, but at the same time, fo r a practical intervention.
In this model, the marginalized embody a system composed of cultural
(i.e., machismo, sexual silence, culturalized health beliefs) and socio-structural
(i.e., poverty, gender-related constraints to health access, racism, migration)
constraints and adapt themselves to the expectations of a superior force (the
system-medical, legal, etc.). It Is at the intersection o f the cultural and
sociostructural constraints that the embodiment o f this system converts
oppression into myths, alienation and fatalism. These in turn, result in the
practice of drug use during sex, sex as escape, sex as survival, silent sexual
encounter, and culturalized reasons fo r not using protection (Appendix C). For
example, there has been a reported gender bias in access to medical care and in
the quality of care received by women. There is considerable evidence that
women experience gender-related constraints on their access to health care
services, especially by poor women (Doyal 1995). Medical knowledge is too
often presented a superior, giving women, little opportunity to speak for
themselves, or to participate actively in decision-making about their own bodies
(Doyal 1995).
The marginalized (I.e., women, the poor) are not conscious of the socio
economic and cultural contradictions within the society, accepting life for “what it
is” and they don’t question injustices done to them. They are silent and docile;
69
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
they may gain insight o f their problems but make no connection with the world
outside. Their lack o f consciousness is fed back into the system and vice versa.
One of the most im portant concepts of Freire's pedagogy of the oppressed is the
“the culture of silence”. Freire used the concept o f “myth” in relationship to the
culture of silence (Freire 1970:97). According to Freire, the oppressed have
internalized “myths” or lies created by the oppressor because they have been
imposed on the oppressed. It is at the juncture of cultural and sociostructural
forces that women internalize the myth typifying women as inferior by the larger
society. Thus, the oppressed (i.e., women and to an extent their customers), feel
ignorant and become dependent on the culture of the oppressors, the experts in
the society (Freire 1970).
The needs of the oppressed and what can be learned from their own
experience are not regarded as important, they are devalued. Marginalized
women are still dependent on male doctors for advice on the use o f
contraception. The women’s own view of their needs is often ignored, their
situations are no considered as real (Doyal 1995). There is a “myth” created by
the cultural invasion of males in medicine for example that sex workers are
vectors of disease (Campbell 1995:197). Women are socialized to adopt this
role and embody or internalize it. The domination of the professional’s world
perpetuates this view because they own the means o f production and
monopolize the system of socialization. According to Freire, humans re-create
themselves through a culture of praxis. Praxis is the integration of reflection and
70
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
action, practice and theory, thinking and doing. Action must happen before or
after reflection. Freedom from oppression and disease is becoming more of a
subject, more human, realizing that one has agency. Women and men have
agency and are capable to recognize and transcend their own boundaries, which
put them in certain restricted situations where they gain more confidence in order
to act. It is at this juncture that a bi-directional model of health education comes
into place, where participants act towards a critical consciousness making
connections with the cultural and socio-economic contradictions in the system
and society. It is my hope that community planners who see the data in the next
chapter, view the community of Mexican immigrants in Long Beach as a context
in which a bi-directional educational program can operate and the vehicle
through which Institutional changes in attitudes, practices, and policies can be
effected. The information gathered from my study population facilitates a
developing partnership among organizations, leaders, and groups who play an
important intervention role as channels of program dissemination.
SUMMARY
There is little written about Mexican immigrant women and HIV/AIDS and
contraceptive use in the area of Los Angeles. Most of the existing literature is
related to the Mexican migration experience as labor migration, and the process
of acculturation focusing mainly on Mexican Americans born in the US. In the
early anthropological studies from 1950-1970 there was an emphasis on
“culturalisf views to explain the health problems of Mexican Americans.
71
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
However, there was a paradigm shift towards a more extensive inclusion of
sociostructural issues, but gender issues related to decision-making, immigration,
sex work, and health remained unexplored. From this literature review, I have
formulated the bi-directional as an explanation of the relationship between culture
and sociostructural forces affecting the health of sex workers and their
customers. W hile theoretical in nature, this approach advocates for the idea
that the study population has agency, and that this agency can be practiced with
action and reflection within the boundaries and constraints of culture and
sociostructural systems of oppression.
72
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER 3
METHODS
This study was conducted In Long Beach, California during the period
1990-1997. My decision to conduct this research began as a result of over six
years o f providing HIV/AIDS prevention education, case management, and other
social services to residents of the Harbor Area, including Long Beach. In the
advent o f HIV/AIDS, I took a job as a Director o f AIDS Services at a local
community-based organization in San Pedro. From 1990 to 1997, I developed,
implemented, and evaluated various HIV/AIDS prevention programs and related
services to women and their families in Long Beach. During my field studies and
outreach activities, I noticed that there were several hidden populations that local
public health officials were not reaching through HIV prevention efforts. One of
these populations was a group of Mexican immigrant women who exchanged sex
for money in cantina (bar) settings. In 1994, I developed a project funded by the
State Office of AIDS (grant #94-18101) to target sex workers in cantinas to
provide them with HIV prevention education and outreach. It was through this
grant that I became involved with this population both as a researcher and
service provider.
In 1995, I became a member o f the State Office of AIDS Community
Planning Working Group, Needs Assessment Committee for the State of
73
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
California HIV Prevention Plan. My duties were to compile data fo r the State of
California HIV Prevention Plan from populations that were at-risk for HIV/AIDS,
and which we knew little about. It was through this membership that I became an
advocate for sex workers and their need for HIV prevention efforts. I learned that
very little was known about sex workers in general, and no data existed on
Mexican immigrant sex workers in cantinas. The only data that existed was from
an epidemiological perspective. Thus, qualitative methods were needed to learn
more about the risk behaviors of these populations. In 1996, Dr. Lynn Miller,
Professor at the Annenberg School for Communication, awarded me funding to
conduct my dissertation research from the Institutional Predoctoral Training
Grant (grant #96-USC-173), Universitywide Research Project. W ith these funds,
I was able to conduct structured interviews (Appendix B) with forty informants
and perform the quantitative and qualitative analysis of the data. I collected the
qualitative data through focus groups, informal interviews, and participant
observations between 1990-1997 when I provided HIV outreach and education
services to the Mexican immigrant community. I feel strongly that my research
and experience will contribute to the understanding of the intimate lives of hidden
populations, in this case Mexican immigrant sex workers in cantinas who are
unlikely to be targeted by either researchers or service providers. The work I
present here Is the result of both my academic interest and my realization of the
need to conduct applied research projects using qualitative anthropological
methods to improve the health of women in these settings.
74
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The Ethnographic Process
This study bears no methodological resemblance to any other studies of
HIV/AIDS among recent immigrants. There were no studies of an ethnographic
nature in Los Angeles-Long Beach that I could use as guidelines. Most of the
studies in this area had been conducted by behavioral social scientists or
epidemiologists (O’Reilly and Higgins 1991 ) and were based on survey research
with strong behavioral and individual orientations. W hile defining the methods I
would use for this project, I wanted to use my insights as an insider, as a Latina
immigrant, to explore the context in which women very similar to me in
background made decisions about their sexuality and prevented HIV/AIDS in
their community. I turned to th& women in my immediate community that is,
other professional women and friends, and family, who thought I was naïve to
conduct sex-related research. Aside from thinking that I was “strange” they
thought my questions were intrusive.
During my ethnographic research, I turned to women who were living with
HIV/AIDS. I met Alicia (pseudonym) at a support group for women living with
HIV/AIDS that I had started at the agency where I was a service provider. Alicia,
a thirty-six-year-old Mexican woman had become infected by her primary sex
partner. Alicia had worked in a cantina as a sex worker and supported her
husband's heroin habit in this way. Her husband eventually died o f AIDS. This
personal experience caused A licia to become an activist for women living with
HIV/AIDS in the Long Beach/Los Angeles County area. She often gave her
75
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
personal testimony on behalf of women infected by HIV in various community
forums and television programs. I asked Alicia and the other women in the
support group how my research could be less intrusive and more useful to them.
To this Alicia responded:
Give us a voice, whatever you do give us a voice.
I'm tired of appearing in talk shows and having a
microphone on my mouth by some reporter and being
told what to say on what cue. Give us a voice, give
women such as me who are unheard a chance to say our
peace. Start from the ground up and give us a voice.
Put our faces behind those numbers show that we are.
Show the world that we are not just a bunch o i putas,
coming to this country to have our kids bom in the US
because we want welfare. Then give our voice to
someone who cares so that at least we can have a
support group or some place to talk about our problems.
I began to formulate my research questions with help from Alicia and three
other women who worked in a cantina with whom I would meet once a month for
one year. Although not all of them were living with HIV/AIDS, they knew they
were at risk, and welcomed my intrusiveness because they trusted me.
However, they still thought I was very “strange” for wanting to know in detail
about their sex life. Although they trusted me, some of the women felt
uncomfortable with questions related to the types of sex they had with men.
Others thought that I might have been a former sex worker at some point of my
life. These four women concluded that in order to help other women avoid
becoming HIV infected, it would take more than my modest research project.
Nevertheless, they remained committed throughout the project to helping me
discover why Latina women were getting infected with HIV.
76
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Although I found women working In cantinas reserved, once I gained their trust,
they became more open about sexual matters. I knew that my real challenge
was to secure the trust of other women who could also participate In the project
Before gaining access to these women, who are very difficult to Identify, I had to
spend more time engaging this community. Therefore, I divided the objectives of
my research Into two phases. The first phase was ethnographic. The second
phase consisted of collecting quantitative data from twenty sex fem ale workers
and twenty male customers. The first phase allowed me to spend time with the
first four women who became my advisors and helped me build trust and rapport
with others. I also conducted Informal Interviews with other women In the
community who were not sex workers, but partners of men who bought sex from
prostitutes. During this time, I wrote a grant proposal that was funded by the
California State Office of AIDS to provide HIV prevention services for women In
cantinas from 1993 to 1995. As a service provider, I had the opportunity to
conduct participant observation In the area on a consistent basis. I now fe lt that I
had a genuine purpose to be In the community, and I wasn’t just an Intrusive
anthropologist.
The first phase began In April of 1990, and continued until December of
1996. During this phase, I conducted participant observation on a monthly basis
for six years. This gave me the opportunity to familiarize myself with the area,
concentrate on community engagement, and build relationships. I also had the
opportunity to become acquainted with key Institutions In HIV prevention.
77
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
While these research activities were conducted, relevant services, staff,
and other community resources were being developed and identified
simultaneously. However, my main focus was to secure the trust of Mexican
women who worked in cantinas who I knew would assist me with my project.
The relevance of the research approach, data collection instruments, and
methods were discussed at length with the advisory group. During this phase, I
organized focus groups of informants. I used my discussions with these groups
to formulate to formulate research tools for the second phase.
The second phase began in January of 1997, and lasted until August of
1998. Phase two represents the quantitative part of the study. During this
phase, I formulated the study questions and developed data collection
instruments with the help of the four original women participating as my advisory
group. I identified the respondents and conducted semi-structured interviews with
twenty male and twenty female participants. The major analysis, theoretical
orientation, and recommendations are based mainly on my data obtained during
the second phase.
During the ethnographic phase, I identified the importance of
concentrating on the sociostructural conditions that determined the kinds of
options available to the study population. The women whom I informally
interviewed and the study community were especially affected by the anti-
78
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
immigrant political climate of the 1990s. This climate was evident in the
development of a set o f electoral policies. Examples of these include mandatory
HIV testing for pregnant women; Proposition 209 (an anti-affirm ative action
initiative); Proposition 187(a policy that denies medical and social service to
immigrants); and 227 (the anti-bilingual education initiative). These policies have
exerted a negative impact on the well-being of the study population. These
structural conditions created an environment in which, immigrant women had
limited choices. About this, one woman stated:
If I have to choose between starving and selling el culo
(selling my ass) guess what would take priority? I have
to feed my kids. Kids ask for food, ask fo r warm clothes.
They don’t understand where you have to get these
things. I don’t have a driver’s license; I don’t have a
social security number or a green card. It is tough for me
to get a job. If someone asks me to do it without a
condom and I need the money, I will do it. I w ill screw
the amigo (client) because I don’t know if I’m going to get
AIDS in a few years from now. But I sure as hell know
that I will die of starvation in a few days or that my kids
will not stop crying for the rest of the night because they
are hungry. That’s painful, that’s my reality. I don’t have
a guy supporting me. I don’t know anyone here but my
amigos.
Alicia and the other women in the advisory group had formulated theories
of self-analysis that came from their own experiences in group discussions about
gender roles, politics, and economics. I would venture to comment that, because
of the stigma of being sex workers, these women were more open and had
greater clarity about their gender roles than the women who did not engage in
sex work in the study community. The sex workers claimed that their awareness
was a result of not having to rely on a man for their support. They attributed this
79
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
attitude to being less tolerant of the sexist attitudes of the men in their families
and the men with whom they bartered sex for money or survival. Regarding this,
one woman stated:
I left Mexico, I left my husband because I would not
tolerate him having a querida (lover or informal second
wife). If I had gotten a lover who could support me, my
own family would have killed me before he would. You’re
always blamed for the sex that goes on in the fam ily. If
your man goes out of the marriage to a prostitute for sex,
it’s because you are not giving him something. If you are
the prostitute in the com er and the cantina and give him
the sex he wants you are also criticized for giving him sex
and being a puta (whore). So, tell me who is more of a
whore, the woman who has to screw this guy no matter
what because she is married to him or me? At least I get
paid by all of them. The woman who stays at home
doesn’t get shit.
Regardless of their occupation, some participants developed multiple
identity strategies as a means to subvert the demands placed on them as
mothers, daughters, wives and community members. Yet, w ithin these shifting
roles, the non-sex workers did not have to deal with being isolated or
marginalized by their families or society because of the stigma associated with
putas (whores). In contrasts, some o f the sex workers experienced
discrimination within their families and communities as a result of their
occupation, an occupation that branded them as mujeres de la calle (bad women
or street women). Unlike the non-sex workers, sex workers in cantinas faced
extreme reactions to their conduct, such as violence, rape, and isolation within
the Latino community as well as within the host community.
80
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Research Design
During the first phase of the study, I led focus groups in discussions,
carried-out participant observation, and held informal individual and group
discussions with several populations. These populations included men who
bought sex, non-prostitute Latina women, and Mexican immigrant sex workers
who had worked or currently worked in a cantina. This was to elicit a variety and
range of relevant ethnographic profiles. I collected the data, seeking the voices
and experiences of the participants by placing them at the center of my research
as my co-investigators. This participatory approach in which I took the role of the
learner and sought the advice of the participants to formulate the research
questions, assisted me in understanding how Mexican immigrant women
mediated cultural expectations, their risk of HIV/AIDS, and economic realities. I
specifically focused on recent immigrant women from Mexico who exchanged
sex for money or survival.
The participant stories centered on their fam ilies and their crossing of
cultural, economic, and political boundaries. Their transformation from wife or
mother to sex worker began when they could no longer exist within the dictates
of their culture, or when they could no longer support themselves or their
children. They embraced the challenge of seeking out their own autonomy
outside the bounds o f culture, family, and society. Some women like, Alicia, left
their husbands in Mexico, breaking through the confines of the traditional roles of
woman and mother to become the sole providers of their fam ilies as sex workers
81
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
without waiting for men to support them. According to Alicia, sex work was a
logical avenue for seeking the greater autonomy that comes with money.
Whenever I could, I would inform ally interview relatives who knew of the
participant’s sexual conduct. Some o f the participants liked having me as an
outsider talk to their relatives for additional emotional support. When I was
invited to family gatherings or community functions, I was able to observe my
participants' family lives outside their sex work. I tried to be as non-intrusive as
possible by creating a safe space fo r the women to discuss their lives. I tried to
make the interview process as inform al as possible so that the women could feel
safe and comfortable sharing their stories with another woman and not simply a
researcher. Nevertheless, my own role as an immigrant, a woman married to an
Anglo, and as a Latina was often questioned (Zavella, 1982; Kondo, 1990). I
became the confidant of many of my participants, and I accepted invitations to be
the madrina (Godmother) to some of the ir children. I tried not to interact with
family members who were not aware o f the participants’ occupations in sex work.
This lack of connection to their fam ilies gave the sex workers the security that I
would keep what they shared with me confidential.
Methods of Procedure
The project had two main objectives:
1 ) to assess female involvement in the decision-making process for HIV/STD
prevention and contraceptive use;
82
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
2) to analyze the sociostructural factors such as poverty and racism that impact
the sexual behavior o f immigrants and their presence in the host community.
In an effort to address these objectives, I focused on assessing the influence of
the environment (i.e., poverty, racism) in the process of decision-making (i.e.,
sexual behavior, use of HIV/STD prevention, and contraceptives). I believed that
different individuals would be exposed to different sexual cultures for a variety of
reasons, not the least o f which would be gender and economics. While my focus
was on the female role in the decision-making process, this role was deeply
intermingled with that of the male sex partner (all o f the women were
heterosexuals), and the political, social and economic context where these
women conducted sex work. My research would not have been complete without
the complementary investigation of male profiles and the impact on the lives of
the women.
Data Collection Procedures
During the first phase of the study, I conducted two focus groups to elicit
the variety and range of relevant ethnographic profiles. Twenty female sex
workers and twenty between the ages of 18-55 were recruited and screened at
the agency where I provided HIV prevention services and in cantinas. The
participants were screened for immigrant status, HIV risk, and previous history of
exchange of sex for money. The men were recruited from my agency’s HIV
testing program. At the same time, the local court referred the men following
83
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
their arrest for soliciting sex workers. They were also recruited from the local
Day-laborers Center in Harbor City. The women were recruited from a total of
fourteen cantinas. These men and women were assigned to two focus groups
with males and females in separate groups. Data from these focus groups were
combined for analysis since the format for both groups was the same. The data
analysis began while the groups were still in progress so that newly emerging
ideas could be fed back into the development of the second focus group.
I designed the structured interview protocol based on data derived from the
focus groups. In order to address the objectives mentioned above, the structured
interview was designed to:
• collect demographic and relevant data on acculturation,
• assess general health and mental health,
• assess the impact of the ethnographic profile on contraceptive and STD
decision-making,
• determine the levels of alcohol and drug use,
• analyze sexual histories.
• determine levels of sexual abuse
• assess HIV status and the utilization of preventive services.
84
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The structured Interview (Appendix B) was quantitative in nature. The data
were also collected and generated from the qualitative analysis. The structured
interviews were conducted in a single format, but men and women were
interviewed separately.
Sampling Techniques
I used a convenience sampling (snowball sampling) method to identity and
interview the participants. Due to the stigma attached to sex work and the illegal
act o f exchanging sex for money in the State of California, most o f the women did
not identify as sex workers or the men as customers. This prevented the use of
random sampling methods in the selection of the sample. Consequently, during
the participant-observation phase of the project, I identified a convenience
sample of twenty women and twenty men who were willing to reveal this part of
their lives. Gaining access to the men was not as difficult as gaining access to
the women. Reaching the women was only possible through the social networks
of several women in the initial advisory group who early in the study understood
and approved of its objectives. One of the women in particular, Gloria, an ex-sex
worker, became a gatekeeper for the study, and helped establish credibility and
rapport with the women who agreed to participate.
85
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Approach
The methodological approach of this study reflects the multi-method research
philosophy espoused by Brewer and Hunter (1989) in which shortcomings of
individual methods are overcome by using combinations of approaches. This
study used both focus groups and structured interview methods in the collection
of data, and used both qualitative and quantitative methods to analyze it. Focus
groups have been used in a variety o f disciplines because the dynamic
interaction of the group often brings forth more insight into the why and how of an
issue (Kruger 1988; Morgan 1988, 1993). In the context of the proposed
research, however, there is a risk that study participants could be inhibited by the
sexually explicit nature o f the subject matter. 1 think this problem was overcome
for several reasons: 1 ) separate focus groups were conducted for males and
females to reduce inhibition; 2) I had developed several techniques for dealing
with this material in a sensitive manner; and 3) the size of the groups and their
demographic composition was adjusted to facilitate open communication. For
example, the focus groups were conducted in the language o f the participants
(Spanish), and each participant attended only one focus group.
The format of the sessions was allowed to evolve over tim e to take advantage
of what was learned in earlier sessions. The primary purpose of the focus
groups was to better understand sexual culture from the point of view of the
participants. In this approach, members of a society are viewed as having an
“ethnographic profile” consisting of particular beliefs, behavior patterns, and
86
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
affective reactions to elements within sexual culture. The sexual culture is in fact
defined by the distribution of the ethnographic profiles over the people in the
society, or the study population, that is, it represents a kind of consensus. The
interviews in the second phase partly provided a rough guide to related
frequencies of the beliefs, behaviors, and affective reactions already defined for
this domain in the study population.
My approach was to map the domain of ethnographic profiles through a
technique termed anchored solicitation. This is a three-stage process conducted
within a focus group's session (Magana & Magana 1980). In the first stage,
participants were asked to name a set of archetypal figures. These figures could
include such persons as “the puta” (the whore), “the married man", the “young
stud” and others. The focus group leader initiates the list by suggesting one or
two figures. Once the group and the leader have defined a list o f figures, the
second stage begins. In this stage, participants are asked to describe the sexual
partners each archetypal figure can have. The third stage requires that group
members discuss the use of condoms in each pairing with an emphasis on what
kind of message is sent by each partner to each partner when the condom is
introduced, for example.
Not all pairing will be germane to issues of contraception and disease
prevention; therefore, another purpose o f the focus group leader will be to steer
the group away from irrelevant parings. It is worth mentioning that it is not the
87
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
archetypal figures, their partner, or the use of condoms by the pairs that
constitute data or findings for the study. Rather, it is the reactions of the
individual participants out of which the ethnographic profiles manifest
themselves. In short, the pairings of archetypal figures are like a Rorschach test
for the group members. By gauging the various actions and reactions that are
discussed as a consequence of group dynamics, a recognizable and retrievable
set of ethnographic profiles can be constructed. For example, I thought that my
data would suggest the circumstances and rationales under which condoms are
perceived to be appropriate or irrelevant.
The structured interviews were built upon the understandings gained from
the qualitative analysis of the focus group data. The structured interview was
used when the researcher became fam iliar with the boundaries, the domain, and
the components of the phenomena, but was unable to anticipate the range of
possible responses of a particular question, and could not structure the answer (
Morse 1992, 1994). This is precisely the situation that I anticipated after the
focus groups' data were analyzed. As mentioned above, I anticipated that the
structured interview would contain sections that would assess the impact of the
ethnographic profile on contraceptive and STD decision-making and in which
demographic and other relevant data could be collected.
Construction of the individual items for the structured interview emerged
as part of the qualitative analysis of the focus-group data. The women in the
88
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
advisory group participated in the choice of the questions used for the interview
guide, with me leading the effort. Interview questions were developed in English
and Spanish. The structured interviews were 1 % hours in length per person and
were conducted with twenty female sex workers and twenty men who frequented
them. The interview was conducted in Spanish and participants were paid
another $20 to complete the interview. The purpose of the interview was to
identity the ethnographic profile of each participant and to assess the impact of
this ethnographic profile on contraceptive and STD decision making. Both men
and women answered each question. Linking information was reserved so that
the responses of the members of the study population could be compared on all
interview items. The interview also elicited demographic information, information
concerning the status of the relationship between the “couple” (sex worker and
client), descriptions of any past or present decisions regarding the use of
contraception or STD prevention. I did not audio taped the interviews, but rather
I took notes.
Description of Data Collected
The focus groups were audio taped. The focus group were transcribed on
a personal computer and preserved in both hard copy and electronic format. The
tapes, hard copies and electronic data files resulting were transported to the
University of Southern California where the data base for analysis was
constructed and maintained as the transcripts were made available. Data from
the focus groups and qualitative aspects of the structured interviews were stored
89
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
in microsoft word and then transferred to QSR NUDIST (Non-numerlcal
Unstructured Data indexing Searching and Theorizing) developed by Qualitative
Solutions and Research Pty Ltd., 1996 (A.C.N. 006-357-213).
NUDIST is a computer package designed to aid users in handling non-
numerical and unstructured data in qualitative analysis. It does this by
supporting processes of indexing, searching and organizing data. Specifically,
NUDIST will help to manage, explore, and search the text of documents, and
generate reports including statistical summaries. NUDIST handles data such as
transcripts of unstructured interviews, field notes, and abstracts by creating a
document database that stores all the recorded textual and non-textual data.
Data from the structured interviews were stored and analyzed using SAS,
Statistical Analysis Software, a quantitative statistical package.
Research Ethics
It was necessary as part of the study to collect information of a sensitive
nature (e.g., illegal sexual conduct, illegal drug use) in order to identity the
individual, social, environmental, and cultural factors that may put women at risk
for HIV/AIDS. This information is central to the development of sound HIV
prevention efforts and appropriate interventions for women in these settings.
Steps were taken to safeguard the confidentiality of the data collected. The data
collected were accessible only to the research staff affiliated with this project and
me. Raw data (interviews) forms were maintained in a secured space. The
90
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
audiotapes of the focus groups were transcribed immediately and the tapes were
erased after the data were summarized and entered into the computer. No
identifying information was attached to the transcripts or any other data collection
instruments. The data were analyzed in aggregate form only. Also, women and
men who participated in the advisory group, as it grew from five to seven
participants, were consulted about the most appropriate ways to share the
research findings with the Long Beach immigrant community. Specifically, the
group asked that the information be used to develop HIV prevention programs
and advocacy groups that included members of the study population as
collaborative partners.
Method of Analvsis and Analysis Plan
This section describes the various operations employed to analyze the
data. This includes the basic approach to the task and the scope of the
endeavor.
Qualitative Analysis o f Focus Groups. As stated above the purpose of the focus
group is to map the domain of ethnographic profiles in the study population. In
the focus groups, participants will display their reactions to the archetypal figures
and situations that define this domain. The purpose o f the qualitative analysis is
to pinpoint relevant profiles from the partially structured responses obtained
during the focus groups meetings. To a large extent, this is a process in which
relevant comments o f the participants are identified and then classified into
91
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
archetypal categories. That Is, the material is analyzed into an intelligible
representation of the information (Tesch 1990). This task was facilitated through
the use of NUDIST, which was designed to deal with relatively unstructured
material such as that occurring during the focus group sessions.
Qualitative Analysis of Structured Interviews. The main purpose of the structured
interviews was to identify the ethnographic profiles and assess the impact of the
interaction between the sex worker and client, and their decision about their use
of contraception or STD prevention. Therefore, the analysis of the data focused
on these two main objectives. Qualitative portions of the structured interview
were entered in Microsoft word and then into NUDIST. This software handles a
combination of structured and unstructured responses. Much of the qualitative
analysis of interview data was focused on the characteristics that define a profile
and whether or not the responses made the respondent eligible for this particular
classification.
The second main objective was to evaluate the way profiles influence sex
worker-client decision making. Here a more classical ethnographic analysis was
employed. I evaluated decision making by the identification of themes (e.g., how
a profile impacts communication and decision making), and variations, (e.g., how
does the influence vary), and if it does, from profile to profile, with convergent
and divergent profiles, with specific profiles, etc. Having applied this process to
several transcripts, I then proceeded to verify the themes and variations already
92
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
identified with new transcripts. Moving through all sex worker-client
comparisons, I then looked for differences in the way they play themselves out
with those using contraceptives versus those using HIV/STD prevention.
Throughout all stages of the analysis, I focused more intensely on the female’s
role in the process.
Quantitative Analysis. Quantitative data from the structured interview
were made easily accessible to analysis because SAS generates a statistical
package. This analysis included: 1 ) descriptive statistics for the sample; 2)
dependent sample statistical tests investigating the differences between the
responses on individual items; and 3) assessment o f the combined effect of
gender and decision making context. The quantitative possibilities are richer then
I first thought because of the many numerical coding possibilities, the size of the
sample, and the flexibility of SAS.
S tudy Site
I conducted this study in the city of Long Beach, which is part of the
Southern/Coastal region of Los Angeles County (HIV Prevention Planning
Committee 1996:34). To follow is a description of the study area, where I found
most of the cantinas. This is to conceptualize the sociocultural context under
which immigrant female sex workers operate and interact with the host
community. This description will also provide a rationale for the applied nature o f
my work. Long Beach is a geographically discrete community, largely
93
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
impoverished and ethnically diverse with rates of HIV/AIDS that are comparable
to, if not higher than, most other areas in Los Angeles County. I believed Long
Beach to be an ideal community in which to conduct the study because o f its high
concentration of Latinos, cantina settings, and the high incidence and prevalence
of HIV/AIDS and poverty.
Disease Profile
Sexually transmitted diseases with the highest reported incidence in Long
Beach include chlamydia, gonorrhea, non-gonoccocal urethritis (NGU), AIDS,
and syphilis. Long Beach has experienced a shift in its AIDS cases among
ethnic groups. In 1982, Anglos comprised of one hundred percent of all reported
AIDS cases. By 1996, this percentage had decreased to fifty six percent.
Conversely, Black and Latino AIDS cases have increased from zero percent in
1982 to over twenty percent each in 1996 (City of Long Beach 1996: 46). For all
reported adult/adolescent female AIDS cases in Long Beach, through December
31, 1996, heterosexual contact was the leading category for exposure (41%).
Since 1982, women compromised 4.7 % of all reported AIDS cases in Long
Beach. For the year 1996, however, women represented 9.3% o f AIDS cases.
This suggests a strong trend in the number of female infected AIDS cases in
Long Beach. Hispanics in Long Beach are becoming HIV infected at a greater
rate than any other ethnic group except African-Americans in proportion to the
total Long Beach population. Moreover, the rate of AIDS cases in Long Beach is
nearly twice the rate for Los Angeles County and over two times the rate for the
94
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
State of California, suggesting an even greater impact of AIDS transmissions for
female Hispanics in Long Beach (City of Long Beach, 1998: 33).
Demographic Profile
The targeted area included the East, North, W est Downtown, and W rigley
areas of the City o f Long Beach. The selected zip codes for these segments are
90804, 90805, 90806, 90810, and 90813 respectively. According to census data,
of the 9.2 million people who live in Los Angeles County, 255,152 live within this
geographic area. As reported in Table 1, 21% of the residents are Anglos, 19%
African American, 21 % Asian/Pacific Islander, and 37% Latino. Long Beach is a
largely impoverished community with the median household income significantly
lower than that of Los Angeles County ($27,325 vs. $38,987 respectively). There
are also more persons living below the poverty level in this area than in the
County of Los Angeles (37% vs. 24% respectively) and a greater proportion of
residents of Long Beach are receiving public assistance than in the County (35%
vs. 19%). There are a greater percentage of unemployed persons in Long Beach
than in the County (10% vs. 8%, respectively). The percent of female-headed
families is comparably higher (29%) than in Los Angeles County (20%). Births to
teen mothers nineteen years old and under are higher (15%) in the target area
when compared to the County (13%). The area is rather young, with twenty five
percent of the residents between the ages often to eighteen years. In terms of
educational attainment, over one-third (37%) of the residents have not graduated
from high school compared to thirty percent in the County (United W ay 1997).
95
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Table 1. Characteristics of Long Beach by Zip code Compared to LA County.
Number
Total Population 255,152
Age
0-4 years
5-9 years
10-17 years
18-24 years
25-64 years
65+ years
Ethnicity
White
African American
Asian/Pacific islander
Latino
Other
Language Spoken
English Only
Spanish
Median Income (dollars) 27,325
Household Income
<$15,000
$15,000-$34,999
$35.000-$49,999
$50,000-$74,999
$75,000-$99,999
> $100,000
Percentage Below Poverty Level
Births to Teen Mothers
Female Headed Household
Public Assistance
AFDC-GG
AFDC-U
Food Stamps Only
Medi-Cal Only
General Relief
Employment Status
In Labor Force 107,153
Employed 96,297
Unemployed 10,854
% Unemployed
Education Attainment
0-8 Grade
9-12 grade
High school Graduate
Some College
Associate Degree
Bachelor Degree
Graduate/Professional
Long Beach
%
11
9
13
12
47
7
21
19
2 1
37
2
53
28
28
34
17
13
5
3
37
15
29
19
4
3
8
1
10.3
19
18
23
20
7
10
3
Number
9,190,990
38,987
4.441.000
4.082.000
359.000
Los Angeles County
%
9
7
11
11
52
10
36
10
12
41
2
54
32
20
28
17
17
8
9
24
13
20
7
2
2
7
1
8.1
16
14
21
20
7
14
8
Source: United Way, State of the County Data Book: 1996-7. Los Angeles, 1996. Note: Data
abstracted from the United Way Data Book represents zip codes: 90804, 90805, 90806, 90810,
and 90813.
96
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Gaps in Services
There are approximately a total of 395 private and non-profit agencies in
all of Los Angeles County providing HIV services. The distribution o f services for
Latinos is 29.7% of these 395 agencies. The majority of services target three
main populations with the highest service provision to women followed by youth
and substance abusers. In spite of the high number of programs targeting
women, those for women of color were few (1.9%), representing less than 15%
of all of the women’s programs (Los Angeles County HIV Prevention Planning
Committee 1996:56). W hile there are programs scattered throughout the
County, the majority clusters in the Central and Western region o f the County
(Los Angeles County HIV Prevention Plan 1996: 57). As a result, significant
gaps in programs exist, with some areas of dense population showing very few
programs. Most programs focusing on women are based in family-planning
clinics where the focus is on basic HIV education, rather than providing in-depth
risk reduction counseling, consequently, significant gaps exist fo r women who do
not use fam ily planning services. Out of five agencies providing HIV services
specifically targeted to women in the study area, there are no HIV prevention
services targeting Latina immigrant sex workers in cantinas. In Long Beach,
there are a total of nine hospitals with HIV programs, yet none of these had a
bilingual case manager. The Long Beach Memorial and Harbor UCLA hospitals
have the highest cases o f HIV/AIDS infected Latinos, nearly fifty percent of their
case management loads, yet there were no case managers to assist the
monolingual Latinas.
97
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
study Setting: The Cantinas
The study setting consisted of cantinas located in the zip codes mentioned
above. These zip codes are located mostly in the poverty-affected areas of Long
Beach. Cantinas are usually clustered along the main streets of these segments
in predominantly Latino neighborhoods. One finds rundown motels, liquor stores,
small Mexican and Salvadorean restaurants, lunch wagons, and street vendors
in their immediate vicinity. Many street vendors sell tropical fruits and home-
prepared foods; others sell inexpensive items such as plastic flowers, blankets
and bootlegged cassette tapes of popular Latino music. Migrant families live in
small shabby apartments located above the cantinas and shops or in apartment
complexes nearby. Bed sheets often cover the apartment windows. At the street
level, graffiti covers the walls, and iron security bars secure the windows of the
buildings. Crack houses and shooting galleries may be located in some of the
motels and apartment buildings with the resulting sale of drugs and street
commercial sex work by Anglo, Black, and Chicano women (US Born Mexican
women).
The Cantina Scene
Typically a cantina is frequented by male patrons who socialize, talking
together at a long bar on high stools or at tables in small chairs. In addition to
socializing with male friends, some men also interact with women, that is, the
cantineras, ficheras, and taloneras. Live musicians or a jukebox provide loud
banda type songs from northern Mexico, or cumbias from Colombia, or salsa
98
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
from the Caribbean as background music or for dancing. In some cantinas, pool
tables provide additional enjoyment for the male patrons. Although cantineras
may play the role of sex worker it is not their principal assignment. They wait on
tables and receive tips in return, and allow men to caress them while they wait on
tables. Their major task is to sell drinks for the cantina owners. Ficheras on the
other hand, approach men to socialize with them at the long bar or at individual
tables with the purpose of getting men to both dance and buy them drinks. Once
a man agrees to dance with or buy her a drink, he is encouraged to buy a drink
for himself. Although not very common, the fichera then gets a commission in
the form of a token or ficha for every drink she sells. These tokens later may be
turned in for cash. A fichera mainly dances and drinks with a man until he runs
out of money and then move on to another potential patron. In return for the
drinks and dancing, she allows men to caress her at no extra cost. Most ficheras
do not like to be kissed on the mouth, therefore their caressing is mostly limited
to stroking and kissing on the neck and shoulders. If the cantineras and ficheras
want to earn extra money from sex, towards closing time they start negotiations
with potential partners. The sexual encounters are carried out only after they
finish their shift in the cantina. Taloneras (women who do sex work) customarily
only play the role of sex worker. As a rule they are isolated from other women
and have turned to prostitution because they cannot find permanent well paying
jobs to support themselves. Since they do not receive any money from the
cantina owners in the form of wages or tokens, their weekly income ordinarily is
99
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
not as substantial or dependable as that of the cantineras or ffcheras. They are
therefore the most marginal women who operate as sex workers in cantinas.
S ocial description
Women who work in cantinas, their patrons, their children, and families
are predominantly Mexicans or Central Americans. Most of the population in
these zip codes is Asian Pacific Islander, African American and Latino and to a
lesser extent, Anglos. There are two main levels of social distancing among
these populations. At one level, there is a physical separation of the cantinas
from the host community combined with the racial and linguistic boundaries that
contribute to socio-cultural distance. At another level, there is an intra-cultural
social separation between the cantina and the rest of the Latino community. The
Latinas who visit cantinas are women who are perceived as sex workers by their
male patrons. For the most part, the male patrons are day laborers or migrants
laborers during off-seasons. Sometimes, the children of these men enter the
cantinas to look for their fathers. The recent Immigrant women who work in
these cantinas are a hidden population because they often lack the social
networks that typify more established immigrants living in the same area. They
are also isolated because of the illegal nature of their work and they also utilize
fewer social services in the area compared to women who do not work in
cantinas.
1 0 0
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The men’s interaction with the white community is more frequent due to
their job-related relationship with Anglo employers and street sex workers who
are mainly Anglo, Black and Chicano women. The problems arising out of
Mexican and Anglo interactions reflect the social attitudes of the entire population
about one another. Latino men for example, have an opinion that Anglo
employers are abusive. Latina women working in cantinas perceive the street
sex workers as injecting drug users, HIV positive and violent, and the rest of the
community as racist. Immigrants have some interaction with other Mexican
Americans or Chicanos in the area, but that is also limited by language, class
and physical distance. Immigrants tend to live in common apartment complexes
and do not identify with their American-born counterparts.
Although there are some community based organizations in the area that
provide services for Latinos, very few provide culturally and linguistically
competent services for immigrants. There are no special services, groups, or
organizations, or assistance for immigrant sex workers of any kind in the area.
Special events and social gatherings for the Latino population in general are
announced in Spanish by a Spanish local newspaper, local churches and the few
Latino organizations. The Mexican immigrant population is not involved with the
host community or the rest of other non-Latino immigrants such as Cambodians,
Filipinos, Laotians, Samoans, and others. This lack of involvement and the fact
that the immigrant community is physically and culturally isolated from the host
community, promotes a negative attitude about one another and contributes
1 0 1
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
greatly to the marginalization of the women and their own community. Thus,
these women are doubly marginalized.
As a consequence, immigrants often are isolated and abused for fear of
being reported to the Immigration and Naturalization Services (INS) or to the
police. One woman, unable to get a driver’s license because she did not have
legal resident documents, reported paying $300 dollars to a man who promised
to get her a driver’s license from the Department of Motor and Vehicles but never
did so. The man took her money and she never obtained her driver’s license.
When she confronted the man, he told her that if she insisted on getting her
money or calling the police he would beat her up or report her to the INS. She
never reported the incident. An immigrant man told of doing gardening for three
days for a person living in the affluent areas of Long Beach and not getting paid.
When the laborer confronted his employer, the employer threatened to call the
police and accuse the laborer of trespassing. These and other narratives depict
the context and social constraints under which the study population conducts
their work and daily lives.
The Sample
I conducted structured interviews with forty participants as part of my
quantitative and qualitative data analysis. Morse (1994) suggests that a sample
size of approximately thirty-fifty is sufficient to achieve “saturation” when utilizing
ethnographic or grounded theory approaches to qualitative data collection. Of
1 0 2
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
these forty participants, twenty were women who acted as sex workers in
cantinas and twenty were men who bought sex from the women. The
participants were paid twenty dollars each to participate in a structured interview
and were given informed consent forms to allow me to interview them formally.
The Studv Population
The study population is a group of Mexican women who immigrated to the
United States from various parts of Mexico and who work as commercial sex
workers in cantinas. This study also included Latino immigrant men who solicited
the women’s sexual services. The male sample was included to assess the
interaction between their sexual practices and the women’s decisions about
adopting HIV/STD prevention and contraceptive practices.
The Women
All of the women in the study population are recent immigrants who
migrated alone and have been in the study area an average of two years. As a
result of their relatively recent migration to the area, only two of the women had
children living with them. The households in which the women lived included
some family members and friends who moved often in of search of employment.
There was a high turnover of new friends and a small number of relatives who
arrived for brief visits. The average length of stay for the women in the sample
was one month in a single household. All of the women migrated for economic
reasons and sex work was the result of their economic need. The women’s
1 03
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
employment was not limited to sex work but it also included vending and
domestic work. All of the women were young, had a low educational level, low
literacy, and lived in poverty.
The exact number of Mexican female immigrants working in cantinas in
Long Beach is difficult to assess because they move often and their household
compositions vary considerably. Moreover, undocumented status and illegal
activity in sex work poses difficulties in assessing their demographic
characteristics. Nevertheless, this group has established itself in different areas
of Long Beach that support their commercial sex work. Their sex work is
marketed mainly to immigrant men from Mexico and Central America who are
patrons in cantinas. The sex work in cantinas also includes waiting on tables,
serving drinks, selling drinks for the cantina owners, drinking with men, being
fondled by men, and as the night progresses having various types of sex in
exchange for money or other goods.
The Men
Unlike the women, the men have been in the study area longer with an
average of four years. More than ninety percent migrated alone without their
wives and children. The households in which the men lived included family
members or male friends who moved often in of search of employment. As in the
case of the women, there was a high turnover of new friends and a small number
of relatives who visited for short periods. All of the men migrated for economic
104
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
reasons but did not engage in sex work. The men’s employment included low-
wage day labor in the areas of construction, gardening, and other low-skilled
jobs. The male population was older than the females. Like the women, the men
had a low educational level, low literacy, and lived in poverty.
It is difficult to assess the exact number of Latino male immigrants who
buy sex in cantinas because they also move often and their household
compositions vary considerably. Undocumented status and illegal activity in the
act of buying sex poses difficulties in assessing their demographic
characteristics. However, it is common knowledge that Latino immigrant men
solicit sex from cantina and street sex workers in Long Beach.
SUMMARY
The main objective of this chapter was to present the methods I used to
conduct a study of Mexican immigrant female sex workers in cantina settings.
This project began as a result of over six years of providing HIV prevention
services to the study population while I was the director of AIDS services at a
local community based organization in Los Angeles County. Since there were
no studies of an ethnographic nature, I decided to conduct a study mixing both
qualitative and quantitative methods in two phases. In the first phase, ! identified
the study population, conducted participant observations, and led focus group
meetings. I used the information from the focus groups to formulate the
questionnaire for phase two. During phase two, I conducted the quantitative part
105
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
of the study that involved forty interviews with twenty female sex workers and
twenty of their male customers.
The methodology included two objectives: one, to describe the specifics of
the female involvement in the decision-making process for HIV/STD prevention
and contraceptive use. And secondly, to describe the dynamics of the structural
environment and the presence of immigrants in that process. I used a
convenience sampling method to identify and interview the participants because
it is difficult to randomize this population. My approach was to use a multi
method research design, using both focus groups and structured interviews. For
the data management, I used NUDIST and SAS. NUDIST was used to analyze
the qualitative data and SAS the quantitative data. The study was conducted in
Long Beach in several cantina settings. I found Long Beach to be ideal for the
study because it has a large number of immigrants, a high incidence of AIDS and
STDs, and a large population of Latinos, mainly of Mexican origin.
106
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER 4
PRESENTATION OF DATA
My research plan was motivated by the belief that previous works of STD
and contraceptive decision making should be conducted within a wider
framework. One way that I anchored this was to look deeply into the lives of the
study population to understand behaviors that can describe the specifics of
women’s involvement in the decision-making process of HIV/STD prevention and
contraceptive use and to look outside the sociostructural factors that impact their
decisions. Within this framework, I expected to find a broader range of beliefs
that more adequately described the population with which I need to share vital
information. Also, I acquired this knowledge to develop the kinds of intervention
and education programs needed to meet this objective.
A Sociodemooraphic Profile of Sex Workers and their Customers
Population Estimates
It is difficult to obtain an estimate of the numbers of immigrant sex workers
and their customers. There is no universal definition of a sex worker or
customer, no official agency has categorized the number of these populations.
Sex workers in cantinas do not identify themselves as sex workers or prostitutes.
They define their primary occupation as meseras or “waitress” and even if they
practice prostitution, they do not define themselves as prostitutes. Immediately
107
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
after I visited a cantina, the women assured me that “there no no putas (whores)
in this cantina, only meseras" (waitresses). Here, I use the term sex worker, as a
person who exchanges sex for money or survival. I prefer to use the term sex
worker because it is the most accurate term to describe persons who exchange
sex for money or survival. According to sex workers in cantina settings, they do
not always engage in sex work. Their own self-definition as waitresses classifies
them as those who are situational and perhaps temporary sex workers.
Demographic Characteristics
Sex workers in Long Beach represent a mosaic of ethnic and cultural
diversity. Among the foreign-born sex workers, most are from Mexico and
Central America, and the remaining from other Latin American countries. I did
not collect data on the overall characteristics of the sex-worker population in
Long Beach; therefore I cannot quantify this data. Table 2 below provides the
demographic characteristics of my sample of twenty female sex workers and
twenty men compared to the overall population of Long Beach including the zip
codes where the study took place. All of the women I interviewed were bom in
Mexico. Birthplace varied among the male customers only slightly, eighty five
percent were born in Mexico while fifteen percent were bom in Central American
and other Latin American countries. I have only made comparisons with the
general population of Long Beach where statistics were available.
108
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
TABLE 2. Characteristic of the sample compared to the Long Beach population in the
selected zip codes.
Females
(20)
Males
(20)
Long Beach Population
(255,152)
Ethnicity
Mexican 100% 85% —
Other 0% 15% —
Latino 100% 100% 37%
Age
18-24 50% 25% 12%
25-65 50% 75% 47%
65 + years 0% 0% 7%
Average number of years in US 2 4 —
Language Spoken
Spanish only 90% 80% 28%
Spanish more than English 10% 20%
—
Both English/Spanish 10% 0% —
Religion
Roman Catholic 90% 90% —
Other 10% 10%
—
Education
0-8 grade 80% 70% 19%
9-12 grade 20% 30% 18%
12 grade and above 0% 0% 63%
Marital Status
Married 0% 50%
—
Single 50% 40% —
Separated 30% 10% —
Divorced 20% 0%
—
Living with spouse/partner 10% 5% —
Median Income (dollars)
<$15,000 95% 90% 28%
$15,000-34.000 5% 10% 34%
$35,000 + 0% 0% 17%
Employment Status
Unemployed 0% 0% 10.3%
Insurance Coverage
Had health insurance 0% 0% 31%
(Demographics for Long Beach are from the City of Long Beach and the 1990 census).
When compared to Long Beach, the study sample Is younger, which Is
consistent with other findings that claim Latinos overall are a young population
(Hayes-Bautista 1994). The women were younger than the men In the study
109
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
sample. For example, fifty percent of the women in my sample were between the
ages of eighteen to twenty-four, whereas only twenty five percent (25%) of the
men fell in this range. There is an even more marked difference between men
and women among those ages twenty-five to sixty-five; women comprised fifty
percent (50%) in this range and men seventy five percent (75%). When
compared to the overall population in Long Beach, it is obvious that the study
population is younger. The overall population in Long Beach consists of twelve
percent (12%) of those between the ages of eighteen to twenty-four, and forty
seven percent (7%) between the ages of twenty-five to sixty-five. The study
population did not include anyone over the age of sixty-five whereas Long Beach
has a population of seven percent (7%) in this category.
The study population was composed of recent immigrants with an average
of two years living in the US for women and four years for men. The study
population is mostly Spanish speaking. Ninety percent (90%) of the women and
eighty percent (80%) of the men spoke Spanish only compared to twenty-eight
(28%) of the overall population in Long Beach. Ninety percent (90%) of the
study population was Roman Catholic and 10% were from other religions
including Protestant and Evangelical. The level of education among the study
population was much lower when compared to the overall population of Long
Beach. Women had a lower education level than the men in the sample and
than the Long Beach population as a whole. Eighty percent (80%) o f the women
had an educational attainment of 0-8‘^ grade whereas seventy percent (70%) of
110
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
the men had completed the grade. The most marked difference was that
none of the study population had an educational attainment above the 12‘^ grade
compared to sixty-three percent (63%) of the Long Beach population. None of
the women in the study sample were married compared to fifty percent (50%) of
the men.
However, of the fifty percent of the men who were married, only five
percent (5%) lived with their spouses or primary sex partners. Only two (10%) of
the women had primary sex partners but were not married to them. One woman
was not legally married to her live-in boyfriend but she referred to him as her
“husband.” Lastly, the study population had a higher incidence of poverty than
the overall population of Long Beach. More than ninety percent of the study
population has a median income below $15,000 compared to twenty eight
percent (28%) of the population in Long Beach. All of the study population
worked in the informal economic sector and none (0%) were unemployed
compared to a little over ten percent (10.3%) of the population in Long Beach.
Thus, the study population is composed of recent immigrants who are young,
Roman Catholic, mostly single, poor, employed in the informal sector of the
economy, and with no health insurance.
I l l
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Sexual History and Sexual Practices
The women and men were queried about their sexual histories and
practices, and their responses are tabulated in Table 3.
TABLE 3. Sexual History
Characteristics (N=40) Women (20) Men (20)
Age of first sexual experience
Under 15 25% 25%
15-16 75% 65%
Over 17 0 10%
Number of sex partners in past 90 days
1-2 20% 0
3-5 30% 35%
6-10 45% 50%
Over 10 5% 15%
Sex-partner gender
Sex with men in the past 90 days 100% 20%
Sex with women in the past 90 days 0 100%
Sex with primary partner in the past 90 days 0 5%
Type of sex
Oral 0 0
Vaginal Sex 10% 5%
Anal Sex 0 0
Sex with sex worker/customer in the past 90 days
Frequency o f contact
1-5 10% 5%
6-10 15% 50%
11-20 40% 20%
Over 20 35% 15%
Type of sex
Oral 20% 0%
Vaginal Sex 100% 100%
Anal Sex 0 25%
Age of First Sexual Experience
On average, both women and men had their first sexual encounter at
about age sixteen. One female respondent reported a first sexual encounter at
age twelve, while the latest age reported was seventeen. Of the males, one
respondent reported a first encounter at age nine, while the latest age reported
112
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
was twenty. Women had their first sexual encounter earlier than men. None of
the women reported having a first sexual encounter above the age of seventeen
while ten percent (10%) of the men reported having a first sexual encounter
above the age of seventeen. The early sexual experience among women is
attributed to their sexual molestation and abuse. Ninety percent (90%) of the
women reported being sexually molested or assaulted at an early age. They
considered these experiences their first sexual encounters.
Number o f Sex Partners
The male customers reported having more sexual partners than the sex
workers did in the past ninety days. Fifteen percent (15%) of the men compared
to five percent (5%) of the women reported having more than ten sexual
partners. More women (20%) compared to men (0%) reported having one to two
sex partners in the past ninety days. Also, more men (85%) than women (75%)
reported having three to ten sex partners. This may be because the women
often had regulars, customers they would see on a regular basis. In some
instances, the women maintained relationships with one regular man for weeks
at a time. The man would give the women money, groceries, or clothing for sex,
engaging with them for weeks at a time during a given month. Women preferred
to have fewer customers whereas the men preferred to have various women.
The women reported wanting fewer customers because this would limit their risk
for violence, HIV/STDs, and ensure their income. Men, on the other hand.
113
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
reported that if they spent too much time with one sex worker in a cantina, the
woman would expect more out of the relationship. Of this, one man commented:
I like the prostitutes from the street because they have sex with you
and you never see them again. If you spend too much time with a
prostitute in a cantina, she thinks she is your girlfriend. The bad
thing about the street women is that they are dirty, they use
needles to inject drugs, and can give you AIDS. The women in
cantinas are clean; they don’t inject drugs.
It is important to note that the men associated risk for AIDS with injecting drug
use behavior and also with “homosexual” behavior as I will explain below.
Sex-Partner Gender
One hundred percent of the men reported having sex with women and one
hundred percent of the women reported having sex with men in the past ninety
days. None of the women had sex with other women. Although the number was
small, men (20%) reported having sex with other men in the past ninety days.
None of the men, however, self-identified as gay. The men with whom these
customers were having sex were putas /ocas or vestidas (male sex workers or
men dressed as women) who frequented the cantinas. In many cases, the
customers were having sex with the same male sex worker increasing their
mutual risk for HIV, if either happened to be HIV positive. It is important to
highlight the high risk associated with male-to-male anal sex because the
customers, as long as they are not penetrated, do not consider themselves
“homosexuals”, and therefore “not at risk for HIV” (Carrier and Magana 1990).
114
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
There was still the perception among the customers that AIDS is a disease
affecting only gays.
Sex with Primary Sex Partner in the Past Ninety Days
Most of the men (95%) and women (90%) did not have a primary sex
partner, that is a wife/husband or girlfriend/boyfriend. This was partly because of
separation from their primary partners at the time of migration. Of the women
(10%) who reported having a primary sex partner, all reported having vaginal sex
only. None of the women reported having oral or anal sex with their primary sex
partners. Of the men (5%) who reported having a primary sex partner, all
reported having vaginal sex only. None of the men reported having oral or anal
sex with their primary partners. This indicates a preference among the men and
women for penetrative vaginal sex with primary sex partners.
Sex with a Sex Worker/Customer
There was considerable variation in the frequency of sexual contact
between the sex workers and their customers in the past ninety days. Although
the women reported fewer sex partners, they reported a higher frequency of
sexual contact. For example, more men (55%) than women (25%) reported one
to ten contacts. Whereas a significant number of women (75%) compared to
men (35%) reported over eleven contacts. This indicates that the women had
fewer customers or partners but had sex with them more often, whereas men
115
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
had sex less often but with multiple partners. Thus, the men were more likely to
infect the women with a STD.
There was considerable variation in the type o f sexual contact between
the sex workers and their customers in the past ninety days. More women (10%)
reported performing fellatio (oral sex on the men) than the men (0%) reported
performing cunniUngus (oral sex on the women). This may be a result of Latino
men’s reluctance to perform oral sex. The men perceived this behavior as “dirty”
because they believed they could easily obtain a STD through the mouth from
the women. One possible explanation for this is that the men do not see
themselves in a subservient position to a woman. The men are not concerned
about the woman’s pleasure; they are customers paying for pleasure, not
reciprocating. Oral sex represented a sexual taboo among the men and women.
Although sex workers (20%) reported that men requested them to perform
fellatio, they stated that the men interrupted the act to engage in vaginal sex.
Sex workers told me that they would only experiment with this type of sex with
men they knew well because they also perceived oral sex as “dirty ”.
The sex workers (100%) and their customers (100%) told me that the
preferred normal or regular sex in the missionary position (man on top), that is,
vaginal sex. None of the men reported having anal sex with sex workers.
However, of the men (20%) who reported having sex with other men, twenty five
percent (25%) reported having penetrative anal sex with putas locas or vestidas
116
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
only. The men claimed they did not know that these men were not women until
they had already engaged in the sexual encounter. One man commented:
One time I got real drunk and went home with this ruca (woman).
She looked like a woman to me. I was grabbing her ass when I
noticed that she was a guy. Since I was already so drunk and had
paid him, I fucked him in the ass. But he never fucked me. If he
tried to fuck me in the ass I would have kicked his ass.
Another men stated that:
Your really think that these men don’t know the men are not
women? They know, se hacen pendejos (they play stupid). They
just like fucking those maricones (men who like men) in the ass.
The think that we are fooled but everyone knows that those putas
locas have a chorizo (Mexican sausage) under their skirt.
The responses from the men evidence their preference for penetration. Only
when the sex worker was male, the men reported anal penetration. All of the
men and women reported vaginal penetration. When the men engaged in sex
with other men, all respondents reported taking the active (penetrative) male role.
Adoption of Contraceptives
The subjects’ responses about contraceptives use is summarized on Table 4.
TABLE 4. Adoption of Contraceptives
Characteristics (N=40) Women (20) Men (20)
Contraceptive use with primary partner in the past 90 days
Used any method of birth control 5% 0
Respondent chose method 100% 0
Type o f method
Pill 100% 0
Contraceptive use with sex worker (customer) in the past 90 days
Used any method of birth control 65% 0
Respondent chose method 100% 0
Type o f method
Pill 55% 0
Depo-Provera 10% 0
Withdrawal/douching 20% 0
No method 15% 0
117
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The Role of Women in Contraceptive Practices
The data indicate that women knew of biomedical methods of birth control,
and used some type of biomedical contraceptive. They were also aware of the
costs associated with their use. However, the women valued using
contraceptives above condoms for HIV prevention because condoms were
expensive. Most of the women used “the pill” for birth control because they
thought condoms were not very reliable. They feared getting pregnant and
having an additional economic burden. Women reported that if they had the
choice of buying a contraceptive that was more reliable than a condom, such as
the birth control pill, they would spend their money on this contraceptive because
they held it as more reliable than condoms to prevent pregnancy.
The Use o f Contraceptives with Sex Partners
One hundred percent of the women reported being the primary decision
maker for the adoption of contraceptives with their primary sex partners in the
past ninety days. Of the ten percent (10%) who reported having a primary sex
partner, five percent (5%) chose the method. One of the women reported that
since her primary sex partner was in jail, she did not use any method of birth
control, as she was not having sex with him, but that she would normally make
this decision. A second woman reported choosing the pill as her primary method
of contraception. She did not use a condom to prevent STDs with him because
she “trusted him”. My observation in this case is that the very protective factors.
118
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
love, and trust, that were to safeguard her against disease, placed her at risk for
a sexually transmitted disease.
The Use o f Contraceptives with Clients
Of all the women interviewed who were asked whether they used a
method of birth control with a client in the past ninety days to prevent pregnancy,
sixty five percent (65%) reported using at least one method of biomedical
contraception. Fifty five percent (55%) reported using the pill and ten percent
(10%) Depo-Provera as their primary method. Depo-Provera is a reversible
prescription method of birth control consisting of an injection that protects the
patient against pregnancy for a full three months. Ninety five percent (95%) of
the women claimed obtaining their biomedical birth control pills and Depo-
Provera injections from Mexico. The women obtained birth control from others
on the black market in the US or from relatives and friends who often brought
these contraceptives from the border. In some instances, women were injected
with Depo-Provera in illegal clinics or by relatives or friends who were
inyectadoras (women who give injections). The women turned to these practices
because they did not need a prescription nor did they have to pay for a
physician’s visit since none had health insurance.
Although the women knew about biomedical methods of contraceptive
use, twenty percent (20%) reported using withdrawal or vaginal douching, and
fifteen percent (15%) reported not using any method at all. Those who did not
119
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
use biomedical methods o f contraceptives reported not using them because
either they did not have money, or because the men did not want to use
condoms. Some reported relying on the men to bring condoms at times,
especially men who were married, but they reported that men who were single
tended not to want to use a condom. Contrary to medical knowledge, the women
believed that withdrawal or vaginal douching were effective methods of
preventive both pregnancy and STDs.
One hundred percent (100%) of the women reported having control about
the adoption of contraceptive methods. When asked why they chose a particular
method, a recurrent theme appeared in their responses. Women’s choices of
contraceptives were based on economic feasibility. Fifty-five percent (55%) of
the women chose the birth control pill to avoid pregnancy. The economic burden
of having an additional child was an incentive to use the pill. Women reported
having sex with clients without a condom because of the money they needed to
survive. Condoms were not used to prevent pregnancy; they were mainly
thought of as a method to prevent HIV and STDs. One of the women
commented that her clients did not like using a condom and that she could at
least count on not getting pregnant using the pill. Of this she commented:
I chose to use the pill all the time because I don’t trust
condoms. I’ve heard that they can break, and that the
virus still can’t get through it. The amigos (customers)
don’t like using a condom. If I bring it up, they get upset
and sometimes they don’t want to pay me because they
feel it didn’t feel the same with it. Some times they think I
have a disease because I bring up the condoms and they
120
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
don’t want to have sex with me. Sometimes I really need
the money and charge them more money without the
condom. I rather spend my money on the pill because if
they don’t want to use one and I need the money, at least
I won’t get pregnant. My chances of getting pregnant are
higher than getting AIDS. I may die of AIDS five years
down the line, I need to survive today, my kids need
food, I can’t feed another mouth in the house.
The Role of Men in Contraceptive Practices
The data indicate that men knew of some biomedical methods of birth
control but were not as knowledgeable as the women. Contrary to the women’s
comments, all of the men felt that using contraceptives was a woman “thing” and
were less aware of specific methods compared to women. The men believed
that the responsibility for using contraceptive methods lay on the women. In their
view, it was women who became pregnant and thus they would have to deal with
the burden of a child, not the men. Like the women, men consider condoms
useful to prevent HIV and STDs as well as pregnancy. Although men reported
that condoms were expensive, as in the case of the women’s responses, they
reported other reasons for not using them. The cost of condoms ranges from
$7.99 to $10.99 for twelve condoms. This cost of condoms is relatively high
considering the men average an income of about $600 per month. Instead of
buying condoms, the men elect to pay for sex and alcohol. It seems that there
was a greater satisfaction among the men in spending what little discretionary
income they had for the purchase of sex and alcohol in a cantina. There were no
condom vending machines in the cantina’s restrooms, making them less
accessible. Men also reported not using condoms because they reduced
121
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
sensation, and they would forget to use one when they were under the Influence
of alcohol or drugs. Men also reported that If they had the choice of buying a
contraceptive or a “good time”, they would spend their money on “having a good
time.”
The Use o f Contraceptives with Primary Sex Partners
None of the men reported using or choosing any method of birth control in
the past ninety days. All of men reported not being involved in their primary
partners’ decision about choosing birth control. The data indicated a prevalent
theme; the female primary partners were the main decision-makers for
contraceptive use, a role the men assigned to the women.
The Use o f Contraceptives with Sex Workers
Of the men interviewed who were asked whether they used a method of
birth control with a sex worker in the past 90 days to prevent pregnancy, one
hundred percent (100%) reported not using a method of biomedical
contraceptives with a sex worker. The data indicate that the men, as in the case
of their sexual practices with primary sex partners, were not at all involved with
making decisions about contraceptive use nor did they know what methods the
sex workers were using. When asked who chose to use a contraceptive method
and why, all of the men responded that they did not choose any method. The
men reported not choosing a method because they believed it was the woman’s
sole responsibility to assure they were protected against pregnancy. The men
122
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
also reported not discussing contraceptive use with the sex workers. This is
consistent with reports of sex workers (100%) that claimed being the primary
decision-maker for the adoption of contraceptive methods and not discussing
contraceptive use with their customers at all.
HIV/STD Prevalence and Prevention Methods Practice
The subjects’ responses related to their prevalence of HIV/STDs and their
use of prevention methods is summarized on Table 5.
TABLE 5. HIV/STD Prevalence and Prevention Methods Practice
Characteristics (N=40) Women (20} Men (20)
STDs
Had a STD in the past 90 days 7(35%) 8(40%)
Types of STDs
Gonorrhea 4(20%) 5(25%)
Syphilis 1(5%) 0
Herpes 1(5%) 2(10%)
Crabs 1(5%) 0
Warts 0 1(5%)
HIV
Ever tested for HIV 1(5%) 8(40%)
HIV positive 1(5%) 0
Prevention with primary partner in the past 90 days
Used condoms 0 0
Respondent chose any method 0 0
Prevention with sex worker/customer in the past 90 days
Used Condoms 5(25%) 6(30%)
Respondent chose any method 5(25%) 19(95%)
Sexually Transmitted Diseases (STDs) and HIV Prevalence
The prevalence of STDs was significantly high among the sex workers
and their customers. Thirty five percent (35%) of the women and forty percent
(40%) of the men reported having had a STD in the past ninety d ays. This
indicates that more men were infected with a STD. Gonorrhea was the STD
123
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
reported most often. Twenty percent (20%) of the women and twenty-five
percent (25%) of the men reported having had gonorrhea. Female sex workers
reported having had other STDs including syphilis (5%), herpes (5%) and crabs
(5%). Customers reported having had herpes (5%) and warts (5%). Although
syphilis and other STDs were not reported as much as gonorrhea, they add to
the high prevalence of these diseases among this population.
A bias in the number of those reporting STDs may exist because the study
population participated in STD or HIV prevention programs at the agency where I
worked. More men (40%) tested for HIV than women (5%) because most of the
men were arrested for prostitution and were mandated testing. None of the men
resulted positive for HIV. One woman was positive for HIV but she did not test at
our project. She had been tested before because her husband, who was an
injecting drug user, infected her. Also, more men participated in the HIV testing
program at the Day Laborer’s Job Center where I provided these services
through my agency, and where I recruited male respondents. The women found
out about their STDs because they showed symptoms and tested for STDs at a
private clinic in their communities; none of them sought testing at the local health
department. At the time of the interview, more men than women participated in
our HIV/STD prevention and screening project.
124
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The Role o f Women in HIV and STD Prevention Practices
The role of women in HIV and STD prevention practices varied with their
primary sex partners versus those practiced with customers. This was partly a
result of very few women having a primary sex partner and their cultural beliefs,
economic, and political factors interfacing with their use of prevention.
HIV/STD Prevention with Primary Sex Partners
None of the women reported using condoms with their primary partners
because “they trusted” them or because the men did not want to use a condom.
None of the women reported being the primary decision-makers in the adoption
of contraceptives with their primary sex partners for the same reasons stated
above. About this, one woman, who was HIV positive, commented:
My husband and I are HIV positive. We have sex without a
condom because he doesn’t want to wear one. He says that we
are both infected already so what’s the use of him wearing one.
Another woman said:
My old man doesn’t like wearing condoms. I trust him, we know
each other well; we have been through a lot together. Besides, he
is in jail right now so he won’t be having any sex with anyone for a
while.
In the first case, it was apparent that the man made a decision to not wear a
condom. In the second case, the woman also did not make a decision to use
condoms because she placed a great deal of trust on the man’s decision. It was
difficult to assess condom use with the primary partners because not all of the
women had a partner.
125
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
HIV and STD Prevention with Customers
When asked whether they used any method or device to protect against
the spread of sexually transmitted diseases with a customer in the past 90 days,
forty five percent (45%) of the women reported using some type of method.
Their choice of methods varied on what method they believed to prevent a
sexually transmitted disease. Only twenty five percent (25%) reported using
condoms. Although twenty percent (20%) reported using withdrawal or vaginal
douching, these two methods are not effective ways to prevent HIV/STD
infection. Contrary to medical knowledge, the women believed that as long as
the man did not ejaculate inside them, and they were not in contact with semen,
they were not at risk for contracting a STD or HIV. Also, the women believed that
vaginal douching immediately after having sex, could be an effective method of
preventing a STD or HIV. These two practices put the women at higher risk for
HIV or STDs because these are not effective prevention methods.
Although twenty-five (25%) of the women reported to have used condoms
with their customers at least some of the time, most pondered this method of
preventive measure against sexually transmitted diseases and were well aware
of the consequences of not using one. When asked why they did not use a
method to prevent a STD, most of the women (65%) responded that they did not
have money to buy both birth control and condoms. They reported that they
chose birth control above condoms because they did not want to become
126
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
pregnant (see Table 6). Sixty percent reported that they didn’t have a condom
handy while engaging in a sexual encounter with a customer.
TABLE 6. Reasons for not using prevention methods
Characteristics (N=40) Women (20) Men (20)
Reasons for not using condoms in the past 90 days
Sex worker needed the money 13(65%) 10(50%)
Did not have a condom 12(60%) 16(80%)
Customer did not want to use a condom 13(65%) 10(50%)
Sex workers did not want to use a condom 0 0
Were under the influence of alcohol or drugs 4(20%) 6(30%)
The women (65%) reported that men refused to use condoms and that
they used this reluctance to use condoms as an opportunity to make more
money. The women reported refusing to have sex without a condom when they
absolutely did not need money to survive. When asked who chose to use or not
use a method to prevent a sexually transmitted disease, twenty-five percent
(25%) of the women reported being the primary decision-maker in choosing a
method compared to ninety-five (95%) of the men who reported being the
decision-makers (see Table 5). None of the women reported that they did not
want to use a condom with customers. Twenty percent (20%) of the women
reported being under the influence of alcohol or drugs while engaging in a sexual
encounter with their customers and thus forgetting to use a condom.
Although a number of women (25%) reported being in control of what
preventive methods they chose, sometimes they did not use condoms. Instead
they resorted to methods that are not effective such as withdrawal or vaginal
douching because men refused to use a condom. Again, according to public
127
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
health knowledge these are not effective methods to prevent HIV or STDs
(Centers fir Disease Control AIDS Hotline, 1998). The data strongly suggested
that perceived economic survival took precedence over condom use.
Barriers for HIV and STD Prevention in the Workplace
In spite of these barriers, the women found creative ways to prevent
sexually transmitted diseases by resorting to various sexual practices. For
example, some of the women would engage in inter-crural sex practices to
prevent disease. One woman reported the following:
I really worry about getting AIDS. It really scares me but
when I need the money, I take my chances. The past six
months have been very difficult for me. I had been sick
for a few months and I really needed the money that’s
why I haven’t used a condom with the amigos. When I
have sex without a condom a lot, I get the guys real
drunk and rub their penis between my legs just below my
vagina and put a lot of cream. They are so drunk they
don’t even notice that they are not inside me.
Another strategy was to include more regulars in their customer lists,
which reduced their number of partners. When women were provided with HIV
prevention education and condoms at their workplace and in settings familiar to
them, they tended to use condoms more often. Women also began educating
their clients and promoting condom use. However, having sex without condoms
took precedence over using condoms due to the women’s economic constraints
rather than their lack of awareness of HIV and STD prevention methods. Using
condoms was not the only difficulty women had to cope with in the workplace.
Other problems stemmed from violence, lack of customer opportunities, and
128
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
under-employment. Women resorted to giving each other support and
establishing social networks to maintain their safety in the workplace, for
instance, from being abused by customers and others. Of this, one woman
commented:
During the winter, we come to work together, when we
leave work we try to hook up with another woman who
has a car. This way we don’t take chances getting
attacked outside the cantina. If I go with a guy who I
don’t know or haven’t seen around here before, I tell one
of the women, who I’m leaving with and where when I
can help it. I try to take these guys to my apartment as
much as I can. But sometimes, I can’t because I don’t
have any privacy there; I live with four people in a studio.
The Role of Men Who Buy Sex in HIV and STD Prevention Practices
The role of men in HIV and STD prevention practices varied with primary
sexual partners versus those practiced with sex workers. This was partly a result
of men (95%) being separated from their primary sexual partners and not having
sexual contact with them in the past 90 days. It also stemmed from the men’s
cultural-specific beliefs, economic, and political factors interfacing with their use
of prevention.
HIV/STD Prevention with Primary Partners
None of the men reported using methods of STD prevention in the past 90
days with their primary sex partner. This lack of use of STD prevention is a result
of men not having sexual contact with primary partners from whom they were
separated, since the women remained in Mexico. However, of the men (5%)
129
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
who reported having a primary sexual partner, all reported being the primary
decision-makers about not using a condom for fear of appearing unfaithful. One
of the men reported having been unfaithful before and transmitting a STD to his
wife. He commented that if he brought up using a condom with his wife, she
would suspect that he was infected with a STD and leave him. The data indicate
that the men were the primary decision-makers when choosing a method of STD
prevention with primary sex partners. This was a result of the men not being
accustomed to using condoms with their primary sex partners as well. If
condoms were introduced, it could be a reason for marital discord.
HIV and STD Prevention Practices with Sex Workers
When asked whether they used any method or device to protect against
the spread of a STD with a sex worker in the past 90 days, men reported higher
STD prevention practices. The men’s choice of STD prevention methods varied
as to what method they believed was most effective. Of the men (30%) who
reported using a method of STD prevention, all reported using condoms. This
indicates that more men (30%) compared to women (25%) reported using
condoms. This is because the men (95%) were the primary decision-makers in
the choice of prevention methods compared to twenty five percent (25%) of the
women. None of the men reported using withdrawal or vaginal douching to
prevent a STD compared to twenty percent (20%) of the women. However, like
the women, the men believed that as long as the men did not ejaculate inside the
women, and their semen was not in contact with vaginal fluids, both men and
130
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women were not at risk for contracting STDs or HIV. Also, the men believed that
vaginal douching immediately after having sex, could be an effective method of
preventing a STD or HIV.
Although seventy (70%) of the men reported not using condoms with sex
workers in the past 90 days, all considered condom use a preventive measure
against sexually transmitted diseases and were well aware of the consequences
of not using one. When asked why they did not use a method to prevent a STD,
their answers varied. Most of the men believed that cantina sex workers, unlike
street prostitutes, were free of “AIDS” because they did not inject drugs, had
fewer customers, and were regulated by the local health department for STDs.
Some of the men believed condoms reduced their sensitivity and their pleasure
during intercourse. One man reported having difficulty getting an erection with
condom use. Others reported condoms to be expensive also; they clearly put
pleasure above their health. Others reported that they did not discuss condoms
with sex workers at all. Only one man reported perceiving that if he brought up
using a condom with a sex worker, she would suspect that he was infected with a
STD. Another man reported not using condoms because “only gays get AIDS.”
The recurrent theme among the men for reasons for not using condoms was not
so much economic, as in the case of the women, but rather that they believed
sex workers in cantinas were “clean”. Some men reported “checking” the women
for STDs. One reported that he sometimes would apply lemon to the vagina to
check for STDs. However, most reported that they would look for color, odor, or
131
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
sores outside the vaginal area. Because of these beliefs, the men felt
comfortable refusing to use a condom with sex workers. When asked why they
had decided not to use a condom with a sex worker in the past ninety days, (see
Table 6), their answers varied considerably.
Fifty percent (50%) of the men reported not using a condom because the
sex worker needed the money; eighty percent (80%) because they did not have a
condom with them; fifty percent (50%) because they (men) did not “want to use
one.” None of the men reported that the sex workers were reluctant to use
condoms. Thirty percent (30%) stated it was because they were under the
influence of alcohol and forgot to use one. The fact that eighty percent (80%) of
the men did not have a condom with them indicates that they either were not in
the habit of using one or did not have access to them. This is partly due to the
men not having the financial means to buy condoms, but also because they put
pleasure above the cost for condoms. The men chose to buy alcohol and pay
more for sex without a condom rather than using that money to buy condoms.
The men also believed that the cantina sex workers were “clean” and posed no
risk to their health. The men (50%) who did not use condoms because the sex
workers needed money, confirmed that they were aware that women were
having sex for survival. Equally critical is the high use of alcohol, which results in
less condom use.
132
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Barriers to HIV and STD Prevention
In spite of these economic and cultural barriers, the men believed that
they could check for the presence of disease to prevent STDs by resorting to
various practices whether effective or ineffective. For example, some of the men
reported checking for green color in the vagina, painful reaction during
penetration, skin spots, and aversion to lemon when applied to the vagina. The
following extracts from my field notes illustrate how men articulated worries about
risk and prevention. The first relates to a single man in his late 30s. He told me
that he trusted his eyes to check for risk, and that he had unprotected sex with
cantina sex workers but not with street sex workers.
I check the women to see if they are clean first. If I
notice that they pull away their body from me in pain, it is
because they are diseased. Sometimes I put lemon juice
and if it burns them and they say it burns them down
there, I don't have sex with them because the got
something for sure. That’s why I don’t have sex with
women on the streets. I found that they often feel pain
when I’ve been inside them and sure enough, most of the
gonorrhea I got, I got it from them.
In this case, the man’s sexual risk was tied with his ideas about cleanliness
Most of the women you see here in the cantina are clean.
Prostitutes are dirty on the streets, they inject drugs and
they are very aggressive. Some will give you a blow job
right there on the street. One time this woman asked me
to pay her first, I did, and then she hit me with something
and took off. I chased her to get my money but her
homeboys came after me. I have also been arrested
before for using prostitutes on the streets. Here in the
cantina the women are cleaner and nicer and the female
cops never come here pretending to be a prostitute. I
don’t feel that I have to use condoms with these women
besides, I check green looking shit down there all the
time.
133
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The perception that cantina women were “clean” because they did not
inject drugs like the street sex workers and could not infect the men prevailed
among the men and they continued not to use condoms. I must note that the
issue of responsibility for condom use and of infecting others arose only in a few
of the men during my informal conversations. This is a result of the men placing
more emphasis on the women being the ones who could infect them. Their
repeated comments that the women were “clean” or “dirty” posed a barrier for
men in adopting effective methods of HIV and STD prevention because the men
do not see themselves as the possible locus of transmission.
Only two of the men spoke of not wanting to infect others, their wives, but
significantly not the sex workers with whom they had unprotected sex. Cultural-
specific beliefs do not encourage men to think of themselves as the locus of
infection because sex workers are often blamed as disease carriers. Because
the men pay for sex, and the women need the money, men are in a better
negotiating position to be in control. This leaves the women with less power to
negotiate condom use. This is more apparent due to the fact that men admitted
that they negotiated condom use with sex workers as a matter of personal
pleasure and were willing to pay more for sex without a condom. This discussion
is not to stigmatize men who buy sex and their lack of condom use. Rather it is
to present the cultural and social context in which men and women engage in
high-risk sex.
134
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Alcohol and Drug Use
Research indicates that unprotected (i.e., not using a condom) sex is likely
to occur when individuals are under the influence of alcohol and drugs (Fenelly
1991). In my study men and women reported a high use of drugs and alcohol.
Table 7 below shows drinking and drug use patterns of both sex workers and
their customers.
TABLE 7. Alcohol and Drug Use among Sex workers and their Customers
Characteristics (N=40) Women (20) Men (20)
Average frequency of alcohol use in the past 90 days
Daily 9(45%) 4(20%)
Several times per week 10(50%) 9(54%)
Once per week 1(5%) 5(25%)
Less than once per week 0 2(10%)
Used any drugs in the past 90 days 9(45%) 9(45%)
Type of drug
Cocaine (snorted) 4(20%) 4(20%)
Marijuana 4(20%) 9(45%)
Valium 1(5%) 0
Crystal 0 1(5%)
Injecting drugs 0 0
Forty five percent (45%) of the women reported a higher frequency of daily use of
alcohol in the past ninety days when compared to the men (20%). None of the
women reported drinking less than once per week compared to ten percent
(10%) of the men. This indicates that women drank with more frequency
because it is part of their job in a cantina to drink with customers. Women and
men were quite open to admitting to their heavy drinking. The data support the
notion that drugs and alcohol use might act as a determinant of risk factors since
twenty percent (20%) of women and thirty percent (30%) of men reported
drinking alcohol or using drugs while having sex. Although more men (70%)
135
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
than women (45%) reported using other drugs such as cocaine, marijuana,
vallum, and crystal, they stated that in many cases their drug use was
“experimental” and that their choice was to drink alcohol. However, cocaine and
marijuana were the two drugs most often used by men (65%) and women (40%).
None of the respondents reported injecting drugs.
Adaptation of the Study Population to the Host Community
The study population has had to adapt to the host community and the new
environment. The urban, crowded, poverty impacted area is not reminiscent of
home where, although poor, some lived in rural communities. The women
appeared to be practical and dedicated to their families. The women attended
their local church, unless they had an opportunity to work during times of
underemployment. However, church attendance for them signified more than a
spiritual ritual for coping with every day life. A link to the church meant
establishing social networks that could provide amistades (friendships) with other
women and families, food, clothing, translation services, or shelter.
Although the women held some folk health practices and beliefs, all were
aware of biomedical illnesses and the interventions and costs related to these.
Some of the folk health-seeking behaviors of the women included seeking a
curandera (woman healer) for limpias (spiritual cleansing) when they felt
depressed. Some sought sobadoras (massage therapists) for physical therapy.
136
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
However, most of the women were aware that medical care was costly and
esteemed its use only if they could afford it. Of this, one woman commented:
Yesterday, my son had an earache. I could not afford to
go to an ear and throat specialist. I am sure there are
some good doctors out there. I know that my son suffers
from ear infections, he is only two years old. Most
children his age suffer from this but I don’t have money. I
took care of my baby. I rolled a newspaper in the shape
of a cone lit it on fire on the top to depress the pressure
from the infection. Then I put an antibiotic fluid that a
friend of mine got from Tijuana, Mexico, and placed it on
a piece of cotton inside his little ear. I gave him 14 of a
Motrin pill and santo remedio (holy remedy) he was fine
in three days. I once went to the doctor and he charged
me so much money just to give me 250 mm more of
Motrin in one pill. They don’t sell Motrin 500 mm at the
drug store. A doctor has to prescribe it to you, but I
figured that I could take twice the dose of Motrin and
save my money. It’s just too much money to go to the
doctor, I just can’t afford it.
Most of the women had left their families, husbands, and children behind
in Mexico. Most of the women lived with relatives or friends in the US. Social
ties were formed prior to coming to the US, or just developed as a result of the
women working in the cantinas or attending church. These ties were of extreme
importance to them and they valued these relationships greatly due to their
recent arrival and the cultural referencing they provided in the host community.
As stated before, church-related networks provided the women with childcare,
food, jobs, housing, friendships, group reference, and transportation. The
women communicated with their families in Mexico by writing to them because it
was less expensive than the telephone. All of the women hid their work in a
cantina for fear of being criticized and, in some cases, ostracized by their
137
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
families. The women communicated to their families that they worked as
waitresses in a restaurant or in a factory. The educational level of the women
was low; none of them reported having finished la preparatoria (high school) in
Mexico. Some could read and write while others could not read or write at all.
Nevertheless, the women had goals that included learning how to read and write
and improving their education by attending school in the future. One of women,
a 39-year-old mother of five, told me a very moving story of how she was
interested in learning how to read and write. Of this she said:
I came here because I left my husband. He couldn’t
afford to support my children and me. He was
unemployed and couldn’t find work. I want to learn how
to read and write and my father is my inspiration. You
know, when I was only 6 years old in my first year of
school, this man shot my father in front of my mother and
me, he killed my papa. Soon after, my mother stopped
sending me to school because I had to work in the fields
with the family. I often dream that my father teaches me
how to read and write. I think he has because I can
count now and recognize the numbers. I want to learn
how to read and write to make my father proud in
heaven.
Another 23 year-old woman attended ESL classes at the local church. All
of the women spoke Spanish only and none of them spoke English fluently. In
one case, the children spoke English and served as brokers for the mother and
others in the community.
138
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Violence and Sex Work
Cantina sex workers face many similar hazards to street drug-injecting sex
workers (Fuililove et ai. 1992; Chavkin and Paone 1992; Brown 1993; Farley and
Hotaling 1995). Sociostrucural factors in their surroundings greatly impact the
level and type of health risks that cantina sex workers face. During times of
economic hardship, for example, sex workers in cantina settings will trade sex in
exchange for money without using a condom if the client insists on not using one.
This puts the women at a higher risk for contracting HIV or a STD from the men
who may also be at risk. In contrast, it appears that men are far more likely to
employ condoms with street sex workers because they associate them with
injecting drug use.
Violence remains a way of life for many women who engage in
commercial sex work in cantinas. Medical anthropologists have paid more
attention on how violence impacts the every day lives of women and men in
general, but not in specific areas such as the cantinas (Das 1996; Farmer 1996;
Kleinman 1996; Scheper-Hughes 1992,1996; Quesada 1998; Nordstrom 1998).
Anthropologists have examined the physical and emotional suffering of the body
that results from disease, and the body itself has been the point of discourse
(Frank 1986; Scheper-Hughes and Lock 1990; Lock 1993). With a more specific
focus, the lives of the sex workers, I describe, illustrate their everyday
experiences with violence working in cantinas and how they have embodied this.
Their lives reveal the human response to violence and their experience
139
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
contributes to our understanding of the process of illness and resilience to the
social, cultural, and psychological consequences of violence.
Violence is common in cantinas and the areas where they are located.
Violence is one of the major problems for women who work in these settings.
Violence is related to gang fights outside of the cantina, drug related shootings,
physical assault by clients, and rapes and assault by non-clients. Two of the
women in my study, reported having experienced unwanted sexual activity
because someone threatened or physically forced them. One incident involved a
rape-related injury. In this case, three men raped, robbed, and beat a cantina
sex worker while she was walking to her house during the early morning. The
woman was critically injured and hospitalized with a head and hip injury, and she
also suffered serious emotional stress compounded by high medical costs due to
her inability to work and lack of health insurance.
Her story as a woman who has endured and survived violence is
important because it illustrates how ideology, social structure, and geopolitics
clash to shape her experiences. What follows, is her own story;
I was walking out of Bellas de Noche (cantina) when
these three cholos (gang members) grabbed me and put
me into their car. One of them snapped the earrings off
my ear lobes, and punched me. I punched him back and
cussed him out and fought and fought. Then one held
me and the other one raped me. When the one raping
me was done the other one raped me too. I suffer from
nervios (nerves) since then. When I walk around my own
home, I carry my fear with me when I walk around the
140
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
market, I carry my fear, my fear of being raped again.
This lives with me every day, it is part of me now but so
is the misery that I lived with in my country. I fear /a
pobreza (poverty), la pinchimiseria (the damn misery)
that I lived with back home as much as I fear being
raped. This is my chance, here, to send money to my
kids so that they don’t have to go through the misery that
I have been through. I want to go back sometimes, but
going back is accepting that I have been raped, I have
been vencida (defeated). The strongest feeling I have
every day is that I can’t go back, those guys that raped
me are not going to make me go back. My kids need
me, they are my hope. The same reasons that I want to
go back to my country are the same reasons that bind
me to this place and why I have to be here, I need to give
my kids a better future.
In another case, which occurred just prior to the beginning of the study, a
young woman suffered a broken leg requiring several months of medical leave
from her job as a sex worker and waitress. The woman was physically injured by
a patron who assaulted her because she refused to go home with him. Unable to
work, she was homeless for several days with a broken leg. Her ability to work is
still impaired by a permanent injury to her leg.
Of this, she related:
I hate the men that want to kiss me. I don’t like being
kissed. Sometimes I fold my lips tight when they
surprise me with a kiss. This amigo (customer) got mad
because I wouldn’t kiss him. Then he offered me more
money to go home with him. I told him no, I was not
interested. Then me mento la madre (he insulted my
mother). I got pissed and wouldn’t serve him more
drinks. I told the bartender about this amigo bothering
me but he said he couldn’t afford losing a beer sale and
for me not to make a big deal of it. As I walked around
the amigo he grabbed me, and pushed me cussing me
out, then he slapped me and started to beat me when
these other two guys got into the fight with him. I fell
back and twisted my leg breaking it, and this asshole
141
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
kept trying to kick me while I was on the floor with a
broken leg. I haven’t been able to work for 11 months
and have a lot of bills. My comadre (co-mother) says
that I’m making excuses. Maybe I am because I don’t
want to work there, I’m tired of working there and putting
up with this shit. My body has taken over me; I just can’t
do it any more. So I started selling tamales and I’ve
been making enough money to pay my keep at my
comadre’s house for now.
Neither of these two women reported their experience with assault to the
authorities for fear of being arrested or deported. Although none o f the women I
studied ever reported being arrested, they still face the risk of being arrested
because prostitution is illegal in California. Two other women reported having
experienced INS raids during anti-immigrant times and faced being deported. If
deported by the INS, the cost of re-entering is quite high. Since their earnings in
a cantina are meager and their production of sex work is interrupted, the women
have to struggle to cross the border again and face even more risks of being
physically assaulted, robbed, raped or beaten up. Considering the size of the
sample and the length of the study, the number of injuries which occurred during
this time indicates the impressive levels of violence experienced by sex workers
and immigrant women (Fullilove et al. 1992; Farley and Hotaling 1995; Fournier
and Carmichael 1998). These stories and illustrations embody the
contemporary relationship between Mexico with the United States and its
immigration politics. More women are migrating to the US in search of economic
opportunity at any cost. The struggle to cross the border and to find employment
subjects them to violence in the routine of their daily lives profoundly redefines
what it means to be female. The women whose stories I have illustrated refused
142
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
to give up and found ways of coping with their misfortunes. For example, one by
refusing to go back to Mexico, and the other by turning to other work as an
alternative to sex work. Their words are a reflection of why women endure such
a painful struggle in times of economic hardship in Mexico and in the context of
their unwelcome presence in the host society.
Unfortunately, there is a lack of statistics about the violence experienced
by this population. Nevertheless, their lives stories show how this political and
economic oppression is resisted and defeated. The women have managed to
create new selves and social networks capable of withstanding and defeating the
environmental violence they experience. It is evident that the women have
demonstrated ways to assert their personal agency and political will in the face of
the illegal nature of their stay and their work. I continuously observed the women
to be dedicated to reconstructing themselves and to establishing supportive
networks in their immediate community.
Sex Work as Survival
The women’s occupation is a result of their first time crossing the border in
search of better economic opportunity. Some of the women agree to work in a
cantina to pay back the fee charged to them for crossing the border. According
to some of the women, their immigration to the US began when their husbands
lost their jobs due to the economic crisis associated with President Salinas de
Gortari and the economic conditions that could no longer support their livelihood.
143
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
One of the sex workers told me a joke while I sat with a group of them in a
cantina during a focus group session. The joke summarized the feeling of the
women about their economic situations and their motivation to come to the US
for better opportunity. While the woman told the joke, the other women laughed
in agreement, but immediately lowered their heads. One could see the sadness
in their eyes due to leaving their relatives and homes in search of a better life that
so far has not proven to be any better than what they left. The women agreed
that their immigration was a result of their poverty in their former communities
and that sex work was primarily a woman’s job. O f this she stated:
I want you to put this joke in your whatever you are
writing. Although I don’t know anything about politics, I
know that this baboso (stupid) ruined our people. Well,
here it goes and you better translate it right. Salinas de
Gortari, our beloved and former president of Mexico,
goes to God and asks to confess his sins. He says to
God, my lord, I am a bad person. I have left my country
in ruins. God replies, give thanks to God my son; give
thanks to God my son. Salinas de Gortari, feeling guilty,
says again but, God, I left the poor women and their men
without food or jobs. I left the children hungry and no
money to bury their elderly! God again replies to Salinas
de Gortari give thanks son, give thanks to God, son of a
bitch that I am nailed to this cross, otherwise I would get
down there and kick your ass. Now does that tell you
why I came here and why I am doing this shit? You don't
see men doing this work even though they came to this
country for the same reasons I did.
Other women reported that they came to the US because their husbands
had a querida (a second informal wife) or because their husbands or other
relatives abused them at home. Of this, one woman stated:
144
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
I came here (US) and ended up in el talon (slang for sex
work) because the fee for crossing the border was $700.
The coyote (the person who helped her cross the border)
wanted the money in a month or else. Where in the hell
was I going to get this much money in a month? The
only way for me was to work as a puta (whore). I was a
puta before anyway and I was giving it for free to my own
husband who had another woman on the side. I was not
going to tolerate that, no way. As a woman I had the
obligation to have sex with my husband, then he would
leave all full of perfume to be with this other woman. He
would spend money on her and take her out while I had
to clean his hairs off my shower and launder his clothes.
If I would say anything he would beat me up. If I would
say anything to my family, my brothers would tell me that
it was my fault because I was not screwing him right.
Here I have sex with these guys and they go home, I
don’t have to clean up after them, nobody hits me,
nobody blames me, and I get paid.
Not all of the women who work in the cantinas exchange sex for money or
survival. Some just work as waitresses who get involved with one man who will
help them economically. Several of the women reported having other jobs such
as selling clothes, home-prepared food, seasonal migrant labor, cleaning homes
and other occupations to supplement their income. Some reported having
worked in farming, vending, domestic labor, food preparation, and in factories.
No one reported having worked as a sex worker in cantinas prior to coming to the
US.
The economic importance of sex work in cantinas is that it provides an
employment niche for women who are unskilled and unable to work in any
another sector of the labor market. The more women work in cantinas, the more
they will increase alcohol sales for cantina owners. With more women in a
145
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
cantina working as dancers or servers, the demand for liquor is intensified by the
patrons. There is a reciprocal relationship between the number of male patrons,
the sale of liquor, and the amount of money women can earn from sex work; one
aspect feeds the others. Consequently, the more intense the women’s work, the
more liquor consumed by male patrons, the greater the risk for HIV/STD
infection. These health risks include not only physical, but also emotional stress.
Thus, sex work conditions produce female-specific labor and occupational health
risks specific to type of work. Sex work is a female task as one of my informants
commented:
You don’t see men doing this kind of work. They don’t
have to live with the physical pain and emotional stress
of feeling fear of being beaten, being raped while you do
it with them. When I was raped and I told one of the
women at the apartments, she knows what I do for a
living, she said, you are a prostitute, how can a prostitute
be raped. That hurt me. Of course I can be raped. This
is the danger of this work but if I could get a job laying
bricks, or doing gardening, I could make more money
and not have to do this work. The other day I went to the
day laborers, where I met you, to look for this kind of
work once and I never got into the labor lottery to get
hired.
The lack of other job opportunities for immigrant women places an
economic stress on them for which women compensate by increasing their work
in the sex trade. Their increased work time increases the length and intensity of
their exposure to occupational health risks. In the context of sex transactions for
money, the relative risk for HIV and STD Infection may differ according to the
type sexual behavior involved. Unlike the sexual encounters of street workers
and their customers, which for the most part involves manual or oral sex and take
146
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
less than 15 minutes (Shedlin 1987; IVIiller etal. 1990), women in cantinas
engage more private, extended sessions, and, for the most part engage in
vaginal intercourse.
The data from my study showed that one hundred percent (100%) of the
women engaged in vaginal sex with customers. This data coincides positively
with the sexual behavior reported by the men in my study who frequent sex
workers in cantinas. One hundred percent (100%) of the customers reported
having vaginal sex with the sex workers. This practice of vaginal intercourse as
a preference by a large majority of Latino female sex workers in California and in
Mexico has been documented in the literature (Brornfman 1998; Roebuck and
McNamara 1973). Although oral sex and anal intercourse are practiced in some
cases, they are the exception and customers pay more for these services that
are considered abnormal by both men and women in these settings (Ayala et al.
1998:104). Clearly the range of sexual service affects the possibility of HIV and
STD transmission because there is a higher probability that a male can infect a
female through vaginal or anal sex. Because women in these settings are
outside the law by the nature of their undocumented residence status and the
illegality of their sex work, their ability to negotiate for safer working conditions is
limited. Women often work long hours without breaks in their unsafe working
conditions. However, they do not use condoms as a result of their financial
vulnerability if a customer refuses to use one. For example, women start work at
about 8:00 p.m. and serve drinks and dance with customers until about midnight.
147
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
often without a break. After they have waited on tables and danced, the women
engage in sex work from about 1:00 am until about 3:00am.
Since the women are not legal employees of the cantina owners for the
most part, there is no employer to enforce breaks. Taking breaks is left to the
discretion of the women, resulting in very long work hours because of the need to
maximize earnings. Some of the women would rather sell a drink and make an
extra dollar than go to the restroom or rest. This poses the potential for urinary
tract infection due to the prolonged retention of urine. Urinary tract infections can
cause irritation of the genital areas which can be a port of entry for HIV or STDs.
The physical consequences include strain to the back from standing during
prolonged periods of time in high heels and exposure to second hand tobbaco
smoke. Although smoking in restaurants and bars is prohibited in California,
patrons smoke in these setting because this law is not enforced.
Additionally, the work requirements in a cantina setting and of sex work,
compromise the women’s ability to properly supervise and physically attend to
their children. None of the women interviewed had access to consistent
childcare. Many relied on anyone available for the day to take care of their
children within the apartment complex in which they lived or within their
immediate neighborhood. As a result, children are often left unattended and
unsupervised for long hours at a time. One woman commented:
148
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Sometimes I feel bad leaving my kids alone. But I don’t
have any choice; I don’t have a steady babysitter
because I never know if I am going to work that night,
you know, doing a date (sex transaction). So sometimes
I can get a neighbor or someone at the apartment where
I live to watch over my kids. I tried to get one of my
young ones into the childcare where women who have
steady jobs go, kindergarten, so that I could have a
steady place to take my kid. But what happened is that
one time I didn’t take my child there because I couldn’t
pay for that day and they kicked me out of the program.
So, sometimes I have no choice but to leave the kids
alone and try to come by to check upon them. Since I
don’t have a phone, I can’t call my kids.
The lack of childcare makes working conditions financially difficult for the
women. For those with children, a great deal of their meager income is spent on
childcare. Because these conditions pose financial problems, they are forced to
work longer hours to earn a living at an occupation that simply maintains their low
socioeconomic status and risk for HIV. The inconsistency of sex work in a
cantina and lack of other job opportunities for immigrant women places an
additional economic stress. Women often compensate for this by increasing their
work in the informal sector. Some, for example, sell home-prepared foods on
street corners, cosmetics, and used clothes, or clean homes. Some travel to
rural areas in northern California to do migrant agricultural work. The sporadic
nature of their compensatory work and the fact that the women are not
employees of the cantinas results in their underemployment and working in low-
paid, part-time jobs that are physically demanding, often hazardous to their
health, and provide no health benefits or other fringe benefits.
149
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Conditions at the Workplace
Work place conditions in cantinas greatly contribute to the occupational
health problems of workers. Cantinas often lack adequate restrooms, washing
facilities, fire exits, HIV/AIDS/STD prevention mechanisms such as condom
vending machines, earthquake preparedness, and first aid equipment. This adds
to the potential for occupational health problems and for long range effects such
as the spread of disease throughout the immediate community. Several major
contributing factors worsen the situation. One is the local health department that
does not regularly supervise these workplaces. This is partly due to the
classification of these settings as small-businesses; ostensibly liquor related
establishments which indeed do sometimes serve food. This exempts them
from close monitoring from regulating agencies.
Another factor is the resistance of government agencies to provide
preventive services for the needs of immigrants. A third reason is that employers
do not make risk management their priority because workers in these settings
are accustomed to work well under these conditions and have learned to cope
with them. One of the cantinas in which I worked as a bartender’s assistant,
helping him with ice and other items behind the bar, had only one unisex toilet
with no sanitary napkins for women or even toilet tissue. The plumbing did not
work adding to the lack of hygiene and the potential for the spread o f disease.
Water for hand washing was not available sometimes. There were neither signs
advising employees to wash hands nor any dispensaries for condoms or signs
150
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
for HIV prevention compared to other non-cantina bars within the same
community.
As I have noted in previous chapters, women in these settings, unlike the
male patrons, have less contact with the host community, making their access to
HIV and STD prevention services problematic. However, I must note that when
the project, in which I worked full time as a director, offered the cantina owners
HIV prevention in the form of condoms to be distributed, they were very open and
supportive of this HIV prevention effort. My staff formed cooperative agreements
with more than sixteen cantina owners who allowed the project to place condoms
in the bathrooms and posters on the walls advising the importance of using
condoms and testing for HIV. Some cantina owners would assist in forming
education groups where women and male patrons willingly participated and
eagerly learned about HIV prevention and testing.
In one instance, a staff member from the local Health Department HIV
testing unit collaborated with our project by supplying HIV pre/post testing and
counseling. This person would draw blood at the cantina from both women and
male patrons to test for HIV and other STD. After two weeks, the health worker
would go back to the cantinas where he administered the tests and give back the
results to the participants. Unfortunately, there was great controversy and lack of
funding for this population as a result of how the project was being implemented.
151
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The staff member from the local Health Department could no longer continue
providing this much needed service as a result of this institutional barrier.
Although some of these workplaces have fire extinguishers, sometimes
their smoke alarms are not in working condition and there are no specific
instructions posted within visible view in the advent of an earthquake or fire. In
other settings, there were no security guards, making work around drunken men
difficult for the women as a result of the fights that often broke out. Some
cantinas were overly crowded and did not follow fire-occupancy codes, making it
difficult for the women carrying drinks to walk among the crowd. This posed
physical stress because of the difficulty of balancing a tray full of beverages while
walking in high heels on slippery floors, floors which are not well maintained.
This poses physical stress to the body because the women have to bend, duck,
and twist to push their way into crowded spaces. Many of the women
complained of strained backs, necks and shoulders, and sore feet at the end of
their shifts.
The women were not only subjected to violence related to conflicts inside
the cantina but also to street violence. Cantinas are often located in lower socio
economic settings where gang warfare and shootings are common. The long
term effects of being exposed to the possibility of being shot or physically injured
causes women to develop a high level of daily stress and anxiety. The cantina,
in which I worked for example, was located in South Long Beach in zip code
152
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
9013. This zip code is one of the Los Angeles zip codes with the highest number
of residents killed by gunfire in 1997 with Latinos and African Americans as the
more seriously affected populations (Los Angeles Times 1998:B6).
While I conducted observations in cantinas, I learned of various health
risks among the study population. Some of these risks are similar to those faced
by the men who are patrons at these settings, but are experienced differently by
the women who work there. The following are examples:
Injuries. Accidental falls by the women were associated with slippery floors while
they carried heavy trays with beverages. Accidental falls while dancing with men
who were heavily under the influence of alcohol. Because the women wore high
heels while working, they were more prone to lose their balance and injure their
ankles. As I mentioned before, falls can also happen because the dancing and
other floors are not usually well kept, offering the women little support while they
carry heavy loads of drinks. This contributed to the possibility of injuries. Of this
one woman reported:
I haven’t been able to work because my back really hurts
me and I don’t have any money to go to the doctor. I
went to a sobadora (a massage therapist) to see if she
could fix my back but it seems that she hurt me even
more. I hurt my back when I was working dancing with
this amigo (customer) who got real drunk and fell on top
of me. I was wearing these high heels and I couldn’t get
a hold of myself, so I fell backwards and he fell on top of
me. This guy was real fat; he had a big belly. I think it
was his big panza (belly) that crashed my back. I can
hardly get up in the morning because I can’t even bend
down to get out of bed.
153
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Physiological Problems. These problems are related to the lack of adequate
maintenance of the building and restroom facilities. Some cantinas do not clean
the floors and the women have to walk on slippery floors around broken glass
and spilled drinks. Also, men often used the toilet facilities and the women
worried about the possibility of being raped in the bathroom. One of the women
reported having been assaulted but not raped:
The cantina where I worked only has one bathroom men
and women use it. One time when I was working at this
place and on my way to use the bathroom, I opened the
door and this guy was there, just standing there. I
couldn't' understand why he had not closed the door. I
asked him if he was going to use the toilet or what, to
hurry up because I had to pee when he grabbed me and
tried to lock the door behind me, he tried to pull my
clothes off, grabbing my crotch. I screamed and
screamed but nobody could hear me because the music
was so loud. Then I hit him on his head with a glass I
was carrying and he passed out. I have never worked
there again. I'm afraid to run into him because I hit him
pretty bad.
One of the most ailing physical disabilities women develop in these
settings is due to the over consumption of alcohol. Women have reported
increasing their intake of alcohol because their work requires drinking with the
men. Some try to dispose of the drinks that men buy for them but is difficult, and
if caught by the men, it is enough to engender a fight and possibly being beaten.
The constant exposure to alcohol lessens the women's ability to walk or carry
their trays while serving drinks. It also places them at high risk for alcoholism.
Some of the women reported not having a history of alcohol consumption until
they began working in a cantina. One woman commented:
154
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Before I started working here I hardly drank the way I
drink now. This job will lead you to drinking. It is the
hardest thing I have ever done in my life, harder than
bending down to pull onions from the fields or working
during the day during the dessert heat to pick grapes.
The men...you have to know how to handle them. You
never let them know that they can intimidate you because
if you do, the amigos won’t pay you. It is hard not to
drink while you turn tricks. It is the only way you can get
enough courage to do it for money.
Not only the women’s ability to be mobile is impaired by alcohol, but also is the
likelihood that they will not remember to use a condom.
HIV and STD Risk from Sex Work. Sex work requires mental adjustments
because the women know that they can get infected with HIV, the disease they
fear most. Such adjustments include pretending to be happy while having sex
and entertaining a man while knowingly that one can get infected with HIV. The
result is that women become very depressed, begin drinking more, and often
forget to use a condom because they are intoxicated. The women become
mentally and physiologically vulnerable to the conditional nature of sex work
patterns.
The socially and economically fostered female behavior related to sex
work burdens women with having to prove that they can cope with the physical,
social, and mental requisites of their work. This is necessary to gain acceptance
by the men who seek them and to secure customers with whom to exchange sex
for money in the future. Women must prove that they can show the men “a good
155
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
time" and that they are not Insinuating that the men have a STD while still
remaining within the confines of proper behavior. Some of the women reported
that the patrons sometimes become offended if they ask them to use a condom
because they feel that the women were insinuating that they were infected with a
STD or that the women themselves wanted to use a condom because they had a
STD. One woman for example who has been working off and on as a sex worker
for two years described her anxiety over being infected with HIV and dying of
AIDS because she has not used a condom several times with customers. Of this
she commented:
Sometimes I wake up soaking wet on the back of my
neck and I think it’s from AIDS... but I think it’s from the
nightmares that I go through at night. I dream that I died
of AIDS and went to hell. I then think of maybe I have it
(HIV) and get really depressed for days and days.
Women’s sex work in these settings and under these conditions is directly
related to their limited participation in the formal sector of the labor force.
Economic, political, and social conditions induce women to participate in sex
work. However, the occupational health risks women are exposed to as a result
of engaging in sex work, is also imposed by the lack of HIV prevention services
among these hidden populations. Moreover, the potential for their health
problems is increased by the fact that the men are not fully aware of the risks of
HIV and STD. In some instances, the men do not how to use a condom
appropriately or are under the impression that the local health department
regulates prostitution and that the women have regular check-ups as in Mexico.
This also consistently impels women to negotiate harder for the use of a condom
156
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
while still making enough money and securing a consistent source of sex work
opportunities. When the women do not m ake enough money from sex work, they
intensify their participation in it, putting themselves at greater risk for HIV and
STD infection. The women’s status as an underemployed labor force has deep
political and economic significance and in this case, it represents a critical
contributor to their occupational health in the United States.
Housing Conditions
The health of the Mexican immigrant sex workers is affected directly or
indirectly by the kind of housing they live in, by its location, by the number of
people living in the household, and by other factors interacting with the dwelling
and its inhabitants. For example, immigrants usually live in apartment
complexes, which are deteriorated, painted with lead-laced paint, lack smoke
alarms, proper fire escape mechanisms, heating, air conditioning, and plumbing,
are infested with rodents and cockroaches and where the property owners and
managers are absentee. These apartment complexes are located on highly
congested streets and neighborhoods where street violence is common. This
places the women and their children at risk of being seriously injured or their
health severely affected.
A common practice among lower-income, Mexican immigrant families is
sitting outside their apartment to socialize and allow their children to play on the
street; increasing their exposure to traffic accidents and violence. While I
157
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
conducted observations in the study area, I learned of two incidents involving two
children who were playing on the street and hit by an oncoming car. There were
several incidents reported of children who were killed in gang cross-fire as they
sat in their family’s car or played in their living rooms (Los Angeles Times, August
8, 1998: B6).
Although a public health department and other health facilities exist in the
city of Long Beach, these are not easily accessible to the immigrant dwellings.
The city of Long Beach is quite large and these facilities are too far from the
immigrant’s homes. These barriers are compounded by the lack of reliable
transportation and their lack of knowledge among recent arrivals of how to use
the transportation system. Furthermore, these services are not utilized for fear of
being deported by the INS or because the staff in these settings are not culturally
sensitive or empathetic to immigrants. During the course of the study, one
incident occurred in which a local health care facility refused to provide outpatient
services to patients who did not bring an interpreter with them. I accompanied
one of the women to this facility. Her child was suffering from an unusual fungus
on his fingers. As we approached the service counter, there was a large sign
that read in capital letters, “no English, no service, if you do not speak English,
you must bring your own interpreter." What was ironic is that the sign was in
English and difficult to understand for the non-English patient population to whom
it was directed.
158
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Most of the immigrant women cannot afford to have a phone because the
installation fee costs approximately $80.00 and the monthly service charge is
approximately $42.00; these fees are beyond the financial ability of the study
population. Several inhabitants sharing the same dwelling and therefore a single
phone further complicate this. Thus, there are usually conflicts arising from
phone calls that are unpaid or unclaimed. Other problems arising from housing
is the size and the composition of the household. One hundred percent (100%)
of the women interviewed reported living in a household composed of relatives
and non-relatives. The units consist of one-bedroom apartments where two
families or up to seven people lived. In one case, one family of seven lived in a
studio apartment, which was approximately 600 square feet. In some cases,
these dwellings lack heating, air conditioning, proper plumbing, laundry facilities,
and parking.
Crowding and its effects are not minimized because the land owners allow
more than two people to live in the one-bedroom apartments or studios to make
a profit. One property owner commented that he would rather rent to “a bunch”
of Mexican immigrants than to those “Mexicans” born in the US because the
immigrants paid the rent on time and did not cause problems. The effects of
overcrowding on the health of immigrants include several factors. These are:
less quiet, reducing the ability of those who work nights to sleep, an increased
level of stress demonstrated by interpersonal violence, potential psychological
danger to children who often witness or hear incidents of household violence.
159
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
and emotional stress related to privacy. Sometimes the dwellings are located on
main streets facing highly traffic-dense and noise-polluted streets, offering limited
privacy or security. Women reported feeling fearful about where they lived
because their dwellings were located where people sold drugs or engaged in
other underground activities. The women are constrained by living in these
housing conditions because their financial ability to cope is decreased by their
low incomes. Consequently, their financial limitation makes them dependent on
the person with whom they have arranged to live and they are unable to locate
affordable housing.
SUMMARY
This chapter presented quantitative data that illustrates a demographic
profile of the study population and how sexual beliefs and cultural practices are
leading to increased risk of HIV/STD transmission among Mexican immigrant sex
workers and their customers in cantinas. The qualitative data presented shows
how the social and economic context in which these behaviors are practiced
contributes to the risk for HIV and STDs. The quantitative data demonstrate that
the study population is young, single in most cases, lacks health insurance, and
lives in extreme poverty. This data also meet the first methodological objective
specified in chapter three, which is to describe the specifics of female
involvement in the decision making process for HIV/STD prevention and
contraceptive use. The results are, perhaps to an alarming degree, that the risk
of HIV and other STD transmission is heightened by the sexual practices of sex
160
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
workers and their clients. Sex workers and their customers often engage in risky
sex for many of reasons, which vary depending on gender, class status, and
cultural beliefs. Women had sex without a condom because they needed the
money to survive since customers were willing to pay them more for not using
one. Women reported not having money to buy condoms and were under the
influence of alcohol while engaging in sexual activity. The need to have sex for
survival and having to drink almost daily as part of their job in a cantina limited
the women’s decision-making power during sexual acts with customers who
often did not want to use condoms. Male customers, on the other hand, had sex
without a condom because they did not want to use one, were under the
influence of alcohol or drugs, and perceived the sex workers as “clean.” This
perception that the sex workers were “clean” stemmed from the cultural belief
that sex work is regulated in the US as it is in Mexico. These cultural beliefs and
practices interfaced with sociostructural forces to make the health issues of this
study population highly complex ones.
The qualitative data met the second methodological objective specified in
chapter three, which is to describe the dynamics of the structural environment.
The results show that environmental factors such as those related to occupation,
health and labor conditions impact the health of immigrants in the host
community. These factors are critical because they pose direct consequences to
the study population’s health and indirect health problems to others in the host
community. Prevention efforts must be systematically implemented among this
161
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
population to avoid the further spread of HIV/AIDS to other populations. The
data presented here pose various implications and require recommendations that
I will discuss the next and final chapter.
162
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER 5
CONCLUSIONS
The main purpose of this study was to gather data necessary to develop
interventions to reduce the risk of HIV among female Mexican immigrant sex
workers and their male customers to prevent the further spread of HIV/STDs.
Public health officials, community based organizations, and policy-makers could
use these data by implementing bidirectional (Magana 1996) prevention
programs specifically targeted to the study population in their HIV/STD
prevention efforts (Moore 1992:528).
In 1998, the California State Office of AIDS (CSOA) requested data about
recent immigrants from researchers in numerous meetings where I participated
as a member of the SOA Needs Assessment Committee. This agency could
develop HIV/AIDS prevention programs that can produce long-term behavioral
changes among these hidden populations to reduce the further spread of HIV
and the high cost of treatment. This task can be accomplished through the
CSOA’s existing needs assessment and resource allocation committees that
have the duty to assess need and allocate funding for local County programs in
Los Angeles specifically targeted to the study population.
163
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Conclusions
The individual cultural experiences of Mexican immigrant female sex
workers and their male customers are embedded in a larger social matrix where
large-scale social forces are translated into personal suffering and disease.
Several key findings from my study illustrate this point:
1) One hundred percent of the women migrated to the US alone. Women
demonstrated a heightened role as family provider since most (95%) were the
sole providers for their families.
2) There was a significant difference in the adoption of contraceptives among
female sex workers and their customers. One hundred percent of the women
were the primary decision-makers in adopting of contraceptives. In contrast,
men were not at all involved in making decisions in the adoption of
contraceptives.
3) Twenty-five percent of the women compared to ninety-five percent of the
men reported being the primary decision-makers in choosing HIV prevention
methods with their customers. This indicates that the women’s role in
decision-making was limited because they could not afford to buy condoms
and men paid them more not to use condoms.
4) Large-scale social forces such as poverty, the impact of migration, working
conditions, and the lack of health insurance, have a significant impact on the
health of the study population.
164
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Culture and Health
The ethnographic and quantitative data show how women’s roles are
changing as a result of migration. All of the women in my sample left their
husbands and their families behind in Mexico by choice, preferring to live on their
own and support their children rather than live with their husbands or families in
Mexico. This is evident by the one hundred percent of the women in my study
who migrated to the US alone and the ninety five percent who were sole family
providers. This also indicates that women’s traditional and cultural roles are
changing as they decide to migrate to the US (Bronfman et al. 1996: 55; Magana
et al. 1996:89). Marriage for the women in my sample was not always a stable
and economically secure state. Some of their husbands and families were
oppressive and some of their husbands were unemployed. One sex worker for
example, reported supporting her husband and his heroin habit. Almost all of the
women expressed a desire to come to the US to be economically independent,
and were the primary supporters of their husbands, children and families.
Although the women exercised some power and independence, they were
afraid to inform family members of their occupation in sex work. Their work was
a source of shame and threatened their position in the family. Almost all of the
sex workers reported that their families were unaware of their sex work activities.
Only one sex worker reported that her husband knew of her occupation as a sex
worker. Another way in which the women show independence is that they
protected one another. For example, if a woman left with a man she didn’t know
165
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
well, she let the others know of her whereabouts. If a man bothered a woman in
a cantina, other women would help her. In some instances, the women gathered
around the man and pushed him away. Women in these settings were extremely
resourceful. The women sold cosmetics, clothing, and other items to customers,
peers, and neighbors to raise additional income. Most of the women wanted to
make enough money to get out of sex work. The women would also have
cundinas; a lottery-type activity held every month at their homes. Cundinas
allowed women to collect their resources and lend money to each other in times
on need.
Women in these situations, however, have limited power. Their exercise
of power is weakened by their perpetual indebtedness to the coyote (person who
brings them across the border illegally for a fee) and the customer's sexual
practices. Men who bring the women across the border illegally charge large
sums of money ranging form $1200 to $3,500. The women do not make enough
money to survive and to pay back these fees, causing them to ask for more
credit. The women are forced to stay in these cantinas until they save enough
money to get out of sex work or get another job.
Another limitation is the unequal relationship between the women and
their customers in negotiating condom use. Men who buy sex have more buying
power to direct decision-making towards not using condoms. Men are willing, in
some cases, to pay more when the sex worker does not use a condom.
166
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Because women need the money, they are often willing to have sex without a
condom. This behavior is intertwined with cultural definitions of what constitutes
a prostitute. Because sex work is transitional in this sense, it does not manifest
itself in clear, well-defined bound categories. Sex work is spread along the
continuum of sexual activities and situations. From an economic perspective,
defining a sex worker is a difficult task. From a cultural perspective, women who
migrate to the US alone and have a relationship with more than one man are
seen as mujeres de la calls (street women) by the larger culture. It is still not
acceptable in Mexican culture for a woman to live alone or have more than one
sex partner. If women are unfaithful to their husbands, or stray away from the
marital bond, they are labeled as mujeres de la calls.
As a result of this work, it is important to look at sex work and women in
new ways. The complexities of women’s lives must be understood in relationship
to their economic responsibilities, emotional relationships, and position in the
larger culture. Effective prevention programs for family planning and HIV/STD
prevention can only be achieved with a full understanding of the complexity o f the
women’s lives. Blaming the women for the sexual behavior of both sexes and for
their own economic struggle while ignoring the behavior of men and the social
and economic conditions which lead women into sex work is shortsighted (Piot et
al. 1984; Day 1988; Darrow 1990; Campbell 1995; Hart 1996). Sex work affects
how women migrate to the US and their other roles in the family and society. If
infected with HIV, women can transmit the virus to their children and primary sex
167
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
partners. For this reason, efforts must be directed at protecting the health of
these women rather than how they may infect men.
The ethnographic and quantitative data illustrate how sexual beliefs and
practices among my study population are leading to increased risk of HIV and
STD transmission. There was a significant difference in the adoption of
contraceptives and HIV/STD prevention among female sex workers and their
customers. One hundred percent of the women were the primary decision
makers in adopting contraceptives. In contrast, men were not at all involved in
making decisions for contraceptive use. Although, cultural reasons for this
behavior occurred, these differences stemmed from economic reasons for the
women. More than fifty percent of the women used the birth control pill as their
primary method of birth control because they feared the financial burden of
pregnancy more than they feared a STD or HIV. Women chose contraceptives
above condoms because they did not have the economic resources to buy both
condoms and birth control. The women’s fear of condom failure reduced their
confidence in the product, and fears about product reliability undermined their
efforts to promote the consistent use of condoms for STD prevention and
pregnancy.
To an alarming degree, only twenty-five percent of the women reported
being the primary decision-makers in choosing HIV prevention methods with their
customers in spite of the high prevalence of STDs. This behavior places the
168
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women at risk for HIV and STDs since the study showed that forty percent of the
men and thirty five percent of the women reported being infected with a STD in
the past ninety days. Ninety five percent of the men, on the other hand, reported
being the primary decision-makers in choosing HIV/STD prevention with sex
workers. This indicates that men had a heightened role deciding STD prevention
because they had money to pay for sex without a condom.
The sexual behavior and cultural beliefs of customers further complicate
the women’s limited power in decision-making, increasing their risk for HIV and
STD infection. The customers reported having more sex partners than sex
workers and there was considerable (20%) male-to-male sexual contact among
the men. There was a preference among the men for anal penetration with other
men and vaginal penetration with women. This compromises the women’s risk
since most (85%) did not use condoms with their customers. A significant
number of women (65%) reported that customers were reluctant to use a
condom. Most of the men (75%) reported not using condoms with sex workers.
Also, thirty percent (30%) of the men compared to twenty percent (20%) of the
women reported being under the influence of alcohol or drugs as a reason for not
using HIV/STD prevention methods. This supports the notion that alcohol use
increases risk factors among men and women.
Gender differences in behavior and allopathic models of disease have
important implications for the successful adoption of HIV and STDs among men
169
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
and women. In line with other studies, my data suggest that the risk for HIV and
other STDs may be heightened by the sexual practices of immigrants (Mishra et
al. 1996). Cultural definitions of relationships (Andrade 1982; Chavira-Prado
1992) may increase the risk of HIV among the study population and pose
significant barriers to effective HIV prevention efforts (Amaro 1988, 1985; Gomez
& Marin 1996). The reality of gender roles and sexual equality among sex
workers in cantinas is that they have limited power in negotiating condom use
with men. Condom negotiation occurs in culturally defined roles where men buy
sex and women sell sex. This context reinforces the male economic dominance
over women because women, in this case, need the money that comes from not
using a condom. It is important to design strategies for HIV prevention that can
help women have more power in negotiating condom use (Ferreira-Pinto, Ramos
& Shedlin 1996; Alegria et al. 1993; Vera et al. 1993; Doyai 1995).
Moreover, men who buy sex see sex workers as vectors of transmission
rather than persons who, for many reasons, may be vulnerable of being infected
by the men themselves (Day 1988; Hart 1996). Men who buy sex, like those in
charge of public health, focus on women who trade sex as those responsible for
heterosexual sexually transmitted diseases. This scapegoating takes place in
the context of Latino culture and a male dominated medical environment where
women are seen as vectors of disease to their male customers. For example,
the issue of responsibility for condom use and infecting others arose only in a few
of the men in my study because they placed more emphasis on the women as
170
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
being the ones who could Infect them. Another example in public health is that
little research is directed to studying the sexual behaviors of customers and how
they may be putting sex workers at risk for HIV.
This issue of women transmitting diseases was evident in the paradoxical
perception among the men that the women were “clean" because the authorities
regulated prostitution as in Mexico. Men reported not using condoms because
they believed the women were “clean” choosing to spend their money in alcohol
and sex rather than condoms. Yet, the men did not engage in oral sex with
women because they thought of them as “unclean”. Some of the men rejected
the practice of oral sex with sex workers because they believed that sex workers
“carried diseases.” According to the men, engaging in oral sex with a sex worker
was a sure way of obtaining a disease (Bronfman & Moreno 1996: 63). Of this,
one of the men responded that “prostitutes can give you a lot of diseases in you
mouth, that is why oral sex is called the beso negro (black kiss). You are in the
dark down there, taking the chance to get a disease”. This belief was repeated
by another participant who said: ”1 never go down on prostitutes, God knows
what they’ve got down there, those women are dirty down there.” It was
apparent that the men had prejudices about the cleanliness of the women.
These attitudes about contraception and STD prevention among the men
in my study are a function of their beliefs about sexual culture, the collection of
experiences and conversations about sex that accumulate through the person’s
171
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
life becoming part of his/her cultural identity. For example, a man who has lived
in a sexual culture where sex work (prostitution) is quasi-legal tends to believe,
correctly or not, that the health of sex workers is protected by the state. As a
result of this protection sex workers are “clean” and there is no need to use
condoms with them. More important to men who share this sexual culture, the
suggestion by a sex worker to use a condom is a tantamount admission of illness
and a guarantee for her that the customer will refuse her services. On the other
hand, a man who has lived in a sexual culture where sex workers are devalued
and seen as vectors of disease, tends to believe that oral sex with these women
is “unclean.” Latino men rejected the notion of oral sex based on widely spread
prejudices. Oral sex is seen as a practice that brings about diseases. (Bronfman
et al. 1996: 63-64). Thus these cultural beliefs are in line with medical opinion
and the various ways in which scientific evidence about STDs is incorporated
with cultural notions of female pollution.
Some of the study population’s beliefs about prevention diverged from
medical knowledge. For example, contrary to current medical knowledge, both
men and women believed that not ejaculating inside the woman and vaginal
douching could prevent STDs. Another recurrent theme in the qualitative data
showed that some men believed that one could tell if someone was infected with
a STD by applying lemon juice to the genital area. According to the medical
model, this view presents an incorrect and risky belief. This belief has been
documented in past studies with immigrants. Of this, Magana et al. state:
172
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
From the point of view of the migrant worker, however, and any number of
other people we might ask, an ulcer or abrasion that responds to the
application of alcohol or other acidic treatment with a stinging pain is being
cleansed, an important precondition of healing without infection. Who of
us does not think back with discomfort at the remembrance of a skinned
knee and the highly predictable appearance of the school’s nurse’s
Mercurochrome bottle? These are the memories out of which such
medical models are made in the minds of patients (Magana et al. 1996:
90).
These models persisted among my study population because they lacked
the bi-directional (Magana et al. 1996) health education needed and access to
health care to address these problems. Bi-directional health education is that
which involves the input of the patient, as well as that of the service provider. In
this modality, the health service providers learn from the patients and integrate
the patient’s beliefs into the health education interaction (Bracho de Carpio et al.
1990, 1998; Magana et al. 1992, 1996; Freire 1970). For example, health care
providers could learn about the beliefs and practices of the study population and
barriers for the adoption of contraception and STD prevention specific to sex
workers and their customers. Providers, in turn, could change attitudes about
condoms by communicating to patients that regular condom use leads to mastery
and thus avoid condom failure.
Social structure and health
The sociostructural context in which my study population practices its
sexual behaviors and health beliefs is critical for intervention. As with any
173
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
preventable and chronic disease, those a t risk for HIV/STDs need prevention and
intervention services to avoid getting infected. However, my study shows that
the structure of my study population’s social network is limited. People with
health insurance maintain good health by access to a large network of health
care providers. These providers are contacted through a directory of
participating physicians, usually furnished by their health plan. Having health
insurance comes with a full-time job in the formal sector. Therefore, health
insurance influences the structure of a social network (Ginzberg 1991; Chavez et
al. 1992; Fournier et al.1998; Hayes-Bautista et al. 1994). Since none of my
respondents worked in the formal sector o f the economy and lacked health
insurance, they had no access to a large network of service providers. The study
population had few employment opportunities because of their lack of English
skills and low educational level. These factors limited their entry into a job that
could provide health insurance. One of the protective factors of my study
population is their large social networks composed by family, relatives, and
friends in Mexico (Vega et al, 1998). These personal networks, which provide
immigrants with emotional and physical support, are eroded once they immigrate
to the US. Without this personal support, my respondents were somewhat
limited in who could help them in times of trouble or financial need.
There was also a cultural distance between public health service providers
and my study population. They were often discriminated by service providers
and residents in the host community. This prevented them from gaining access
174
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
to HIV prevention and other health care services. This finding is consistent with
those of Skjerdal et al. (1996) who found that negative attitudes toward
immigrants and lack of appropriately targeted services to them inhibited their use
of prevention services. According to their study, women faced greater barriers
than men in gaining access to preventive or medical services. For my
respondents, barriers included limited prevention services targeted to them. The
women in my study were more likely to be Isolated because they did not work in
jobs where they had contact with the host community and they feared getting
arrested by the INS.
The Impact of Migration
The literature as well as the data gathered in my study point to an overdue
explanation of conditions linking the recent migration of Mexican women to their
health status once they arrive in the US (Chavira-Prado 1992; Donato 1993;
Salgado de Snyder 1994; Barchas 1998). In line with the literature cited,
Mexican women come to the United States with more frequency than in the late
1980s in search of better economic opportunities not offered in their country of
origin because the US has labor demands that Mexicans have traditionally
fulfilled (Salgado de Snyder 1994).
In spite of the many perspectives offered in the literature to analyze the
phenomenon of immigration, Mexico and the United States are interdependent
through a series of economic and sociocultural exchange (Gamio 1930; Elac
175
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
1961; Bustamante 1981; Cornelius 1984; Tienda 1983; Chavez 1992. 1994,
1996). However, there is still debate on whether this interrelationship is equal,
economically based, or primarily Influenced by push or pull factors (Guidi 1993;
Borjas 1996; Kennedy 1996). In spite of these debates, the historical political
relations between the United States and Mexico have been sustained by a long
standing economic exchange, of which Mexican labor migration has been a
permanent fixture.
Although not always economically equivalent (Borjas 1996), this exchange
exists and will continue to exist in the construction of the United States economy
and social fabric. Evidence of this perspective is the reliance of the United
States on Mexican agricultural and unskilled labor for its overall economy
(Chavez 1994, 1996; Borjas 1996). From a structural perspective, Mexican
labor in Los Angeles County has existed because of local needs and reliance on
Mexican low-wage labor. Mexico and the United States, through their political
and economic inter-dependency, have historically encouraged emigration and
immigration. This process has created a continuous social, economic, and
cultural exchange from both sides of the border, which is orchestrated within the
structure of institutions.
My study findings showed that because they immigrated to the US
illegally, none of my study participants had health insurance ora regular doctor
because they did not work in the formal sector of the economy where they could
176
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
have access to medical benefits. Unable to afford health care, the study
population resorted to self-medication or gaining access to some type of health
care in the black market. For example, women often bought contraceptives from
the black market or obtained them from friends, and relatives who bought them in
Mexico. These findings are in line with the theoretical perspectives of Chavez et
al. (1992), Vega et al. (1998) and Chavira-Prado (1992), and facilitate the
understanding of the relationship between health and migration.
Chavez et al. (1992) suggest that we should concentrate on a political
economy analysis and its influences on migration and utilization of health care.
Chavez concludes that if structural barriers to health care were to be diminished,
such as the lack of health care coverage, immigrants would be more likely to
seek health care. Chavez et al. points out that coverage of health insurance
significantly influences use of health services and that the uninsured are much
less likely than the insured to have used US health services. However, various
regulations that constrain immigrant's use of health services coupled with jobs
that pay minimum wage and limited or no health insurance, influence immigrants
not to gain access to health care (Chavez et al. 1992:9).
These economic factors are based on the position immigrants occupy in
the US labor force. Chavez et al., like other migration researchers, contends that
the unequal economic and power relationship between Mexico and the US,
where the US is at the advantage, has traditionally pulled Mexican labor to the
177
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
us. As they arrive to the US, these new immigrants fit into jobs in the labor
market which do not afford them access to health care or the social upward
mobility to secure health care resources (Portes 1978; Wood 1982; Sassen
1988; Chavez 1992). Taking Chavez’ approach, it seems the United States
represents potential resources for immigrants beyond Mexico’s geographic
boundaries but once in the US, these new arrivals face barriers of access to
health care.
The work of Vega et al. falls along the lines of Chavez et al. conclusions.
Vega et al. suggest that despite low-income levels, Mexican immigrants have
cultural protective factors that result in less prevalence of mental disorders.
Although Vega et al. do not make a macro-level analysis to migration and health,
their data suggest that environmental factors through the process of acculturation
have dangerous effects on many aspects of the health of immigrants (Vega et al.
1998: 782). Vega et al. calls for an in-depth analysis o f the association of length
of residence and socialization into American culture as factors compromising the
health of immigrants.
Chavira-Prado’s work concurs with Vega et al. and Chavez et al. but goes
further by calling more attention to the role of women in migration and health.
Chavira-Prado concludes that besides the structural constraints women face in
the labor force and their significant cultural contributions to the health of the
family, they also face gender constraints within the cultural ideal of gender
178
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
hierarchy. Gender structure is shown to be dichotomous which is further affected
by the surrounding material conditions (Chavira-Prado 1992:53). Work and
health conditions affect the role of women. On the one hand, their role in
migrating to the US and seeking health care is enhanced. On the other, they still
remain subordinate to men within the family structure and subordinate to the
work place within the social structure. In turn, Chavira-Prado concludes, “women
are subordinated within the home because they are subordinated within the work
place and in the host society" (Chavira-Prado 1992:63).
In line with the work of Chavez et al. , Chavira, and Valdez et al., the data
from my study suggest that women and men migrated as a consequence of
economic conditions in Mexico. These economic conditions have been the
political instability and severe recession after Mexican president Salinas de
Gortari’s rule. The data also suggest that more women migrate seeking better
working conditions and wages, which in turn are to help them gain access to
health care. Men and Women in my study expressed the need to secure
employment that offered a good benefit package to provide health coverage for
themselves and their families. This expression for sound employment, they
believed, would lead to health insurance coverage and better health. However,
their occupational related health conditions and the strategies developed to cope
with these have not secured the resources necessary to ensure better health.
Consequently, immigrant women and men in my study had low health status and
179
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
health problems directly related to their social position as immigrants, as
unskilled laborers, and as sex workers in the host community.
The Impact of Sex as Labor on Women
The work conditions affecting the health of Mexican immigrant sex
workers and their customers influences them to adopt ineffective HIV prevention
methods for coping with risk which are reflected in their patterns of limited health
care use and need for survival. For example, women in my study reported a high
use of alcohol and drugs while having sex. Forty five percent of the women
reported a higher frequency of daily use for alcohol compared to twenty percent
of the men. This indicates that women drank alcohol with more frequency
because drinking is part of their jobs in the cantina. These working conditions
pose an occupational hazard to women who place themselves at risk for
alcoholism and STDs.
Although women had an enhanced role in adopting contraceptive
methods, this role was diminished when choosing HIV and STD prevention
methods due to their limited power in negotiating condom use with their
customers and their lack of access to HIV prevention and contraceptive services.
For example, due to their need for survival, female sex workers in my study were
more likely not to use a condom if the customers paid more money. When
women could not find other types of employment available, they resorted to sex
work, which placed them at higher risk for contracting HIV or STDs. Because of
180
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
their participation in a labor force for which there is no health care coverage and
because of their lack of political clout, there is little structural support for
immigrant Mexican women conducting sex work to secure access to health care
and HIV/STD prevention and contraceptive services (Andrade 1982; Chavira-
Prado 1992; Alegria et al. 1993; Amaro 1995; Campbell 1995).
Mexican immigrant sex workers enjoy greater decision making when
choosing contraceptives but this agency is minimized when choosing HIV/STD
prevention (Day 1993; Doyal, 1995; Ferreira-Pinto et al. 1996). Women in these
situations are forced to work in a labor market, sex work, which does not provide
the sufficient material resources to improve their health or maintain behavioral
changes for the prevention of HIV and STDs. This oppression of Mexican
immigrant women is representative of their familial, social, and economic position
in the host society (Mellville 1980; Urdaneta 1980; Fernandez-Kelly 1983; Mays
& Cochran 1988; Deren et al. 1997).
The role of immigrant women in the family has been emphasized
(Chavira-Prado 1992; Salgado de Snyder 1994; Salgado de Snyder et al. 1996),
but little attention paid to the role of immigrant women in the sex industry and
their customers (Day 1993; Hart 1995). It is important that the role of women in
the sex industry and its relationship to the social structure be included as it
interrelates with women’s other domains. Within an anthropological tradition, an
even more holistic perspective to such analysis would include the role all societal
181
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
structures for changes in relation to each other, as well as how these changes
reflect women’s social, economic, political and other contexts.
Recommendations
Research am ong ethnic subgroups is critical. These data indicate the
importance of conducting research on and targeting specific ethnic subgroups for
HIV/STD prevention. The label sex worker o r prostitute complicates important
differences regarding the use of HIV prevention among men and women. That
is, it is important to research the different motivations women have for trading sex
for money and then use that information for appropriate interventions. For
example, some women may be motivated to practice sex work to buy drugs
whereas others are involved in sex work mainly for money or survival. For
women who engage in sex for survival for economic reasons, prevention efforts
must be directed at not only reducing HIV risk, but also on gender-specific
programs that support the social, economic, and legal measures that improve the
status of women. For those involved in sex work because they need to buy
drugs, drug treatment programs must be incorporated as part of the intervention.
More attention must be focused on a micro and macro analysis on the study of
migration and health among Mexican immigrant women to the United States.
The work of Chavira-Prado (1992), Salgado de Snyder et al. (1996) and
Organista and Organista (1997) suggest that researchers should focus on a
structural and cultural analysis both. My suggestions for researchers working
with HIV/STD and contraceptive use among the study population are several.
182
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
First, researchers must integrate their studies with community-based
organizations that have access to these populations. Second, researchers must
link their findings to policy-makers to identify the study population in data sets.
This is important because funding is often based on the visibility of the population
in the literature. Lastly, researchers must use a multi-method approach to
research hidden populations. Qualitative and quantitative data collection
measures are useful to collect data in urban settings, where the unit of analysis is
far more complex.
A bi-directional approach in public health. Health service providers
must learn from their patients and take the role of the learner. This approach
places the patients and the providers in a partnership where the problem of
prevention is their responsibility (Magana et al. 1992; Bracho et al. 1998; Freire
1970). According to Magana et al.: “it is the willingness to learn and be
educated as part of the education process that consigns the problem of
prevention to the patient and provides him with the psychological wherewithal to
assume responsibility for it” (Magana et al. 1996: 91).
A government response to sex work HIV/STDs prevention. An
information campaign is unlikely to fully resolve the issues of gender in equality
and traditional sexual behaviors that have been practiced by men for many
years. One alternative would be to regulate sex work in these settings as it is in
183
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Mexico and Las Vegas. If sex work were regulated as it is in Las Vegas or
Mexico, women would be less at risk for HIV and have more access to condom
use and primary health care. Studies in Mexico, for example, have reported a
low seroprevalence rate of HIV among registered sex workers in Tijuana.
Registered sex workers in Tijuana have to undergo periodic health screening and
testing for STDs and HIV (Mishra et al. 1996). Studies in Nevada have shown no
known cases of HIV transmission at the Nevada brothels (Deren, 1997: 203).
Sex workers working in the brothels are licensed by the state and undergo
periodic health screening. Rules requiring safe sex practices are strictly enforced
in the brothels (Campbell 1991: 1367-1378). Regulation would ameliorate the
lack of communication between the sexes and their differences in the exercise of
power regarding sexuality as major barriers for the modification of risk practices.
I would also strongly recommend a focus on the customers. For example,
men who buy sex should be targeted by prevention programs and encouraged to
use condoms and get tested for HIV and STDs. Men who buy sex must be made
responsible for using safe sex methods because the effect of legislation may lead
them to assume that sex workers are “clean” and disregard that they have the
potential to infect the women. Prevention programs must involve the men in all
aspects of the intervention. There is the possibility that these policies, such as
the ones suggested, may drive sex workers underground and not come forward
for health screening. However, if implemented correctly, women could benefit
from these measures. One, sex workers would have access to health screening
184
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
and testing because they lack health insurance and is unlikely that they would
gain access to these services otherwise. Two, regulation would give way to
prevention and treatment of disease. Three, it will disarm the police and a whole
host of other individuals who oppress women in these settings. I believe that this
measure will not to drive sex work underground. HIV prevention cannot be
achieved in an environment where sex workers feel stigmatized and fearful. In
the same token, HIV prevention cannot work in a sexist culture where men are
not made responsible for their contribution to the risk of HIV and STDs among
sex workers.
Health, insurance, services, and participation m ust be more
accessible. Employers must be mandated to provide full health insurance
coverage for part-time and full-time employees regardless of residency status.
Outpatient medical facilities and public health care settings should be mandated
to provide an integrated HIV and STD prevention effort with family planning and
other reproductive health care programs. At the local level. Community Planning
Working Groups must be mandated and monitored by the State Office of AIDS to
involve male and female immigrants in their HIV Prevention planning process.
The Centers for Disease Control must increase its funding to the State Office of
AIDS and the Los Angeles County to promote research among immigrants so
that cost-effective services may be provided. Funding should be increased from
the Centers for Disease Control and the Office of Maternal and Child Health
Clearinghouse to provide culturally competent and linguistic-relevant outreach
185
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
and educational materials to female immigrant sex workers and their male
partners. Attention must be focused at providing services to sex workers in
cantinas and in settings familiar and at times convenient to them. These services
must be conducted with the use of promotoras (peer health educators) who can
use and build upon current health approaches to HIV education and behavior
change. Models of behavior change must be based on a grounded theory using
a participatory approach. Freirian methods of popular education and
participatory health interventions have proven to work well with this population
(Magana et al. 1992; Bracho et al. 1998; Freire 1970).
The most important approach of HIV intervention is not only the use of
outreach peer staff that will help overcome issues of language barriers, time
constraints, transportation and financial assistance, but also an approach to
address the female sex worker’s economic development and reinforce their
sense of independence. Culturally and linguistically appropriate projects are not
enough if the issues of women in the economic market are not resolved through
self-sufficiency. During 1994 and 1995, I implemented a project named “Three
Tries and You Are In”, this program proved to be effective in placing female sex
workers, whose own initiative was to leave prostitution, in self-employment, skills
training, and job placement as a strategy to prevent HIV in their lives. This
project was effective as a result of the participation and collaboration of the
California Women’s Economic Development agency and private small
businesses in the local area that provided invaluable resources for the
186
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
participants. This project was evaluated as part of the contract and showed that
a significant number of women became self-employed or were placed in jobs.
Others completed skill training in workshops related to job seeking, and English
as a second language.
Service providers must be cognizant of the economic, social, and political
forces, preventing sex workers and the men who frequent them from making
behavioral changes. Before HIV prevention interventions are implemented at the
individual level, service providers must respond to issues of poverty and limited
participation in the political and decision-making process both at the local and
state level. At the community level, service providers must make sure that while
they provide HIV behavioral services, they must include the target population in
advisory boards, HIV planning group committees, and testimony-giving at public
official gatherings to create a true process of transformation.
Finally, it is imperative that service providers from the HIV/STD sections of
public health and family planning organizations work towards a collaborative
effort in providing integrated HIV/STD and family planning services for women.
Community based organizations that do not have clinical services or family
planning services but provide HIV education, HIV prevention case management,
and behavioral counseling must make an extra effort to link sex workers to
affordable family planning. Likewise, family planning service providers must
make a greater effort at securing funding to provide HIV and STD screening and
187
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
testing combined with family planning services. Overall, service providers must
focus both on the need to provide both family planning and HIV/STD prevention
methods that are likely to be adopted by the study population.
Binationa! efforts with border health. It is apparent that Mexico and
the United States will continue to struggle with issues of immigration. For this
reason, service providers must make a greater effort to involve Mexican and
Mexican American health care professionals, researchers, and others in
cooperative partnerships with those in charge of the Mexican border health and
other public and private representatives to prevent the HIV/AIDS.
My recommendations reflect a need to understand the cultural and the
social, political, and economic context in which Mexican immigrant sex workers
exchange sex for money if HIV behavioral and educational programs are to be
effective. The sex workers social system is the main focus because it
determines how this population will respond to practices related to sexual
behavior and the management of disease, in this case the prevention of
HIV/STDs. I have provided examples of programs that have worked in engaging
the study population in protective behavioral practices against the infection of
HIV. I have also shown the causes and impact of barriers to behavior change
and community participation and inclusion. The need to change individual
behavior which is embedded in cultural meanings, interfacing environmental
188
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
forces such as poverty and limited inclusion in the political, economic, and health
care system poses a great challenge to us as anthropologists.
In the face of these problems, anthropology cannot afford to be the
cultural broker in health care any more. Merrill Singer (1995) in his work titled
“Beyond the Ivory Tower: Critical Praxis in Medical Anthropology”, argues for the
possibility of an applied critical medical anthropology in health settings. Singer
challenges us all to “move beyond the academy into the applied field of clinics,
health education, development of projects, the private sector, and community
based agencies.” (Singer 1995: 81). Although Singer’s challenge poses a huge
order, anthropologists working in the field of HIV/STDs and contraceptive use will
continue to face the challenge of improving the scientific method that leads to
sound theory in the prevention of HIV and disease in general. Within this effort, I
provide the latest findings in the literature combined with the findings of my study
focused on HIV/STD and contraceptive health issues related to Mexican
immigrants living in Los Angeles-Long Beach area. Additional studies are
needed that will produce more rigorous methods and beneficial insights for our
understanding of disease in the area of HIV/STDs, contraceptives, and the
political economy. It is my hope that the work I presented here will make a
positive impact for changes in policy, organizational structure, and funding for the
prevention of HIV/STDs among Mexican immigrant sex workers and their
customers.
189
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
SUMMARY
This chapter summarized the conclusions and recommendations based on
my study findings while supporting them with those prevalent in the literature.
The main purpose of the data summarized in this chapter is to emphasize the
need to develop interventions for HIV and STD prevention targeted to Mexican
immigrant sex workers and their customers. Several key findings from my study
illustrate the cultural and sociostructural experiences of the study population in
relation to their risk for HIV. These findings showed that women migrate to the
US alone and their role as family provider is heightened once they migrate.
There were significant differences in the adoption of HIV/STD prevention and
contraceptives among female sex workers and their customers. Women
exercised considerable power within their family domain and in their choices for
contraceptive use. However, women exercised limited power in decision-making
related to HIV/STD prevention. A final key finding was that large-scale social
forces such as poverty, the impact of immigration, working conditions, and the
lack of health insurance had a significant impact on the health of the study
population.
My study calls for several recommendations for the prevention of HIV
among the study population. Researchers must target specific ethnic subgroups
for HIV/STD prevention. Qualitative and quantitative methods are useful in urban
settings where the unit of analysis is more complex. A bi-directional approach to
public health, which integrates the belief system with that of the medical model is
190
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
useful in dealing with the cultural beliefs of the study population. A government
response to sex work for HIV/STD prevention, which includes regulation of sex
work is suggested. Regulation would provide access to condom use and health
screening and testing for women who lack the resources to secure this benefit.
Regulation would ameliorate the lack of communication between the sexes and
their differences in exercise of power regarding sexuality and condom use. HIV
prevention programs must make a special effort to target men who buy sex. Men
who buy sex must be aware they their sexual behaviors place sex workers at risk
for HIV and STDs and that it is imperative to use condoms. Health insurance,
services, and participation in these services must be made more accessible to
the study population in general. Lastly, service providers must make a greater
effort to involve Mexican and Mexican American health care professionals,
researchers, and others in cooperative partnerships to reduce the further spread
of HIV and STDs.
191
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
BIBLIOGRAPHY
Alegria, M., Vera, M., Robles, R., & Burgos, M.
1993 A cry for help: sex workers perception of the institutional response to their
needs in Puerto Rico. International Conference on AIDS 9(2): 934
abstract no. PO-D33-4297, June 6-11.
Altman, D.G.
1995 Sustaining interventions in community systems: On the relationship
between researchers and communities. Health Psychology 14(6):526-536.
Alvarado, Anita, L.
1980 The status of Hispanic women in nursing, IN M.B. Melville, ed.. Twice a
Minority: Mexican American Women. St. Louis: The C.V. Mosby
Alvarez, Salvador.
1971 Mexican American community organizations. El Grito 5: 91-99.
Andrade, J.S.
1982 Family roles of Hispanic women: stereotypes, empirical findings, and
implications for research, IN Hispanic Research Center, ed.. Work, Family
and Health: Latina Women in Transition. Monograph no. 7. Bronx, New
York: Ford ham University.
Amaro, H.
1995 Love, sex and power: considering women’s realities in HIV prevention.
American Psychologist 50: 437-447.
1988 Considerations for prevention of HIV infection among Hispanic women.
Psychology of Women Quarterly 12:429-433.
Arguelles, L., Rivero, A.M., Reback, C.J., & Corby, N.H.
1989 Female sex partners o f IV drug users: a study of socio-psychological
characteristics and needs. Int. Conf. AIDS 5:760 (abstract no. Th. D. P.
12), 1989 Jun 4-9.
Ayala, A., Carrier, J., Magana, J. R.
1996 The underground world of Latina sex workers in cantinas IN S.I. Mishra,
R. F. Conner, and R.J. Magana, eds., AIDS Crossing Borders: The
Spread of AIDS among Migrant Latinos. Boulder, Co: Westview Press.
Baer, H.A., Singer, M., & Johnsen, J.H.
1986 Toward a critical medical anthropology. Social Science and Medicine
34(8): 95-8.
192
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Baer, Roberta, D. and Bustillo, Marta.
1998 Caida de mollera among children of Mexican migrant workers: implications
for the study of folk illness. Medical Anthropology Quarterly 12(2): 147-
250.
Barchas, Jack, D.
1998 Immigration and mental health: why are immigrants better off? Archives
General Psychiatry 55(9): 781-782.
Biddle, W.W. and Biddle, L.
1985 The Community Development Process: The Rediscovery of Local
Initiative. New York: Holt, Rinehart & Winston.
Borjas, George.
1996 The new economics of immigration: affluent Americans gain; poor
Americans lose. The Atlantic Monthly (278): 72-80.
Bracho de Carpio, A., Carpio-Cedraro, P., Anderson, L.
1990 Hispanic families learning and teaching about AIDS: a participatory
approach at the community level. Hisp. J. Beh. Sci. 12:165-176.
Bracht, N.
1988 Community analysis precedes community organization for cardiovascular
disease prevention. Scandinavian Journal of Primary Health Care 1:23-30.
Bronfman, M. and Lopez, S.
1996 Perspectives on AIDS/HIV prevention among rural migrants on the USA-
Mexico Border, IN S.I Mishra, R.F. Conner, and R.J. Magana, eds., AIDS
Crossing Borders: The Spread of HIV among Migrant Latinos. Boulder,
CO: Westview Press.
Browner, C.H.
1994 Margaret Clark’s enduring contribution to Latino studies in medical
anthropology. Medical Anthropology Quarterly 8(4): 468-475.
Brewer, J. and Hunter, A.
1989 Multimethod Research: A Synthesis of Styles. London: Sage Publications.
Brown, B.
1993 Women impacted by violence and substance abuse: a San Francisco
needs assessment. The San Francisco Commission on the Status of
Women.
193
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Bustamante, J.A.
1981 The historical context of undocumented Mexican immigration to the United
States, IN A. Rios-Bustamante, ed., Mexican Immigrant Workers in the
USA. Chicano Studies Research Center Publications, Anthology NO 2,
University of California, Los Angeles.
California Department of Health Services, State Office of AIDS.
1996 California and the HIV/AIDS Epidemic: The State of the State Report.
Sacramento, CA: State Office of AIDS.
Campbell, C.A.
1990 Women and AIDS. Social Science and Medicine 30(4): 407-415.
1991 Prostitution and AIDS, and preventive health behavior. Social Science and
Medicine 32(12): 1367-1378.
1995 Male gender roles and sexuality: implications for women’s AIDS risk and
prevention. Social Science and Medicine 32: 1367-1378.
Carrier, J.M. and Magana, J R.
1991 Use of ethnosexual data on men of Mexican origin for HIV/AIDS
prevention programs. Journal of Sex Research 28: 189-202.
Carrillo, J.H. and Hernandez, A.
1988 La Migracion femenina hacia la frontera norte y los Estados Unidos
[Femenine migration to the Northern border and the United States], IN G.
Lopez-Castro, ed., Migracion en el Occidente de Mexico. Zamora
Michoacan, Mexico: El Colegio de Michoacan.
Cates, W. & Stone, K.M.
1992 Family planning, sexually transmitted diseases and contraceptive choice:
A literature update- part I. Family Planning Perspectives 24(2): 75-84.
1992 Family planning, sexually transmitted diseases and contraceptive choice:
A literature update- part II. Family Planning Perspectives 24(3): 122-128.
Centers for Disease Control and Prevention
1999 HIV/AIDS hotline, April 6.
Centers for Disease Control and Prevention
1992 HIV infection, syphilis and tuberculosis screening among migrant farm
workers in Florida. MMWR 41(39): 723-725.
Chavez, L.
1992 Shadowed Lives: Undocumented Immigrants in American Society. Fort
Worth, TX: Harcourt, Brace, Jovanovich College Publishers.
194
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
1994 The power of the imagined community: the settlement of undocumented
Mexicans and Central Americans in the United States. American
Anthropologist 96(1): 52-73
1996 Immigration reform and nativism: the nationalist response to the
transnationalist challenge, IN J. Perea, ed.. Immigrants Out!: The New
Nativism and the Anti-Immigrant Impulse in the United States. New York:
New York University Press.
Chavez, L., Flores, E.T., and Lopez-Garza, M.
1992 Undocumented Latin American immigrants and U.S. health services: an
approach to a political economy of utilization. Medical Anthropology
Quarterly 6(1): 6-26.
Chavez, L., Hubell, A.F., McMullin, J.M., Maritinez, R. G., and Mishra, S.l.
1995 Structure and meaning in models of breast and cervical cancer risk
factors: a comparison of perceptions among Latinas, Anglo women, and
physicians. Medical Anthropology Quarterly 9(1): 40-74.
Chavez, L., Conrnelius, W., and Oliver, W.J.
1986 Utilization of health services by Mexican immigrant women in San Diego.
Women and Health 11: 3-20.
Chavkin, W. and Paone, D.
1992 Drug Treatment for Women with Sexual Abuse Histories. New York:
Chemical Dependency Institute, Beth Israel Medical Center.
Chavira-Prado, A.
1992 Work, health, and the family: gender structure and women’s status in an
undocumented migrant population. Human Organization 51(1): 53-64.
City of Long Beach.
1996 City of Long Beach Health Statistics: 1996. Long Beach, CA: Department
of Health and Human Services.
Clark, M.
1959 Health in the Mexican American Culture. Berkley, CA: the University of
California Press.
Cornelius, W.A.
1983 Competing paradigms for the study of Mexican immigration, IN A. Valdez,
A. Camarillo, and T. Almaguer, eds.. The State of Chicano Research:
Family, Labor and Migration Studies. Stanford Center for Chicano
Research.
195
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
1984 Health problems and health services utilization among Mexican
immigrants: the case o f San Diego. Center for Mexican Studies,
University of California, San Diego.
Darrow W.W.
1990 Prostitution, parental substance abuse, and HIV-1 in the United States, IN
M. Planted., AIDS, Drugs, and Prostitution. London: Routledge.
1992 Assessing targeted AIDS prevention in male and female prostitutes and
their clients, IN F. Paccaus, J. Vader, F. Gutzwiller, eds.. Assessing AIDS
Prevention. Birkhauser Verlag: Basel.
Das Veena
1996 Language and the body: transactions in the construction of pain.
Daedalus 125(1): 67-92.
Day, S.
1993 Dealing with marginality: anthropological perspectives on HIV risk
reduction among prostitute women. Paper presented at the conference on
HIV/AIDS in Europe: The Challenge for Anthropology. South-bank
University of London.
Day, S.
1988 Prostitute women and AIDS: Anthropology. AIDS 2(6): 421-428.
Deren, S., Sanchez, J., Shedlin, M., Davis, W.R., Beardsley, M., Des Jarlais, D.,
Miller, K.
1995 HIV risk behaviors among Dominican brothel and street prostitutes in New
York City. AIDS Education & Prevention 8(5): 444-56.
Deren, S., Sanchez, J., Shedlin, M., Davis, W.R., Balcorta, S., Beardsley, M.,
Sanchez, J., Des Jarlais, D.
1997 Dominican, Mexican, and Puerto Rican prostitutes: drug use and sexual
behaviors. Hispanic Journal of Behavioral Sciences 19(2): 202-213.
Donato, Katherine, M.
1993 Current trends and patterns of female migration: evidence from Mexico.
International Migration Review 27(4): 748-768.
Doyal, Lesley.
1995 What Makes Women Sick: Gender and the Political Economy of Health.
New Brunswick, NJ: Rutgers University Press.
Duhl, L.
1986 Health Planning and Social Change. New York: Human Sciences.
196
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Elac, J.C.
1961 Employment of Mexican Workers in U.S. Agriculture, 1900-1960: A
Binational Economic Analysis. University of California, Los Angeles.
Escobar, J.l.
1998 Immigration and mental health: why are immigrants better off? Archives of
General Psychiatry 55(9): 781-2.
Estebanez, P., Futch, K. & Niagara, R.
1993 HIV and female sex workers. Bull WHO, 71: 397-412
Estrada, L.
1987 Mexico-U.S. migration: demographic characteristics of immigrants. Paper
presented at the first Binational Conference on Migration and Mental
Health: Psychological Aspects. Guadalajara, Mexico.
Farley, M. and Hotaling, N.
1995 Research study of prostitutes. San Francisco Examiner, April 16.
Farmer, Paul.
1996 On suffering and structural violence: a view from below. Daedalus 125(1):
261-283.
Farmer, P., Connors, M., Simmons, J.
1996 Women, Poverty and AIDS: Sex, Drugs, and Structural Violence. Monroe,
ME: Common Courage.
Fereira-Pinto, J., Ramos, R., & Shedlin, M.
1996 Mexican men, female sex workers, and HIV/AIDS at the US-Mexico
border, IN, S.l Mishra, R.F. Conner and R.J. Magana, eds., AIDS Crossing
Borders: The Spread of HIV among Migrant Latinos. Boulder, Co:
Westview Press.
Fernandez-Kelly.
1983 For We Are Sold: I and My People. Albany: State University of New York
Press.
Finkler, K.
1994 Women in Pain: Gender and Morbidity in Mexico. Philadelphia: University
of Pennsylvania Press.
Foster, G.
1953 Relationships between Spanish and Spanish American folk medicine.
Journal of American Folklore 66: 201-247.
197
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Fournier, A., and Carmichael, 0.
1998 Socioeconomic Influences on the transmission of Human
Immunodeficiency Virus infection. Archives of Family Medicine 7: 214-
217.
Frank, G.
1986 On embodiment: a case study of congenital limb deficiency in American
culture. Culture, Medicine and Psychiatry 10: 89-219.
1998 Frank, G., Blackball, L , Michel, V., Murphy, S.T., Azen, S.P., & Park, K.
A discourse of relationships in bioethics: patient autonomy and end-of-life
decision-making among elderly Korean Americans.
Freire P.
1970 Pedagogy of the Oppressed. New York: Continuum Publishing.
Fullilove, M.T., and Lown, A.
1992 Traumatic experience of women crack users. The Journal of Sex
Research 29(2): 275-287.
Fumento, J.
1990 They myth of heterosexual AIDS. New York: Basic Book.
Gamio, M.
1930 Mexican Immigration to the Unites States. Chicago, III.: University of
Chicago Press.
1931 The Mexican Immigrant: His Life-Story. Chicago, III.: University of
Chicago Press.
Gastelum, M.A.
1991 Migracion de trabajadores Mexicaoos indocumentados a los Estados
Unidos [Migration of Mexican undocumented workers to the United
States]. Mexico, D.F.: Universidad Nacional Autonoma de Mexico.
Gagnon, J.H.
1988 Sex research and sexual conduct in the era of AIDS. Journal of Acquired
Immune Deficiency Syndromes 1(6): 593-601.
Garro, LG.
1998 On the rationality of decision-making studies: decision-making models of
treatment choice. Medical Anthropology Quarterly 12(3): 319-340.
Ginzberg, E.
1991 Access to health care for Hispanics. JAMA 265(2): 238-241.
198
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Giocoechea-Balbona, A.
1994 Why we are losing the AIDS battle in rural migrant communities. AIDS
and Public Policy Journal (9)1: 36-48.
Gomez C., Hernandez, B.A., Faigeles, B.
1999 Sex in the new world: An empowerment model for HIV prevention in
Latina immigrant women. Health Education and Behavior (26) 2:201.
Gomez, C. and Marin, V.B.
1996 Gender, culture, and power: barriers to HIV prevention strategies for
women. The Journal of Sex Research 33(4): 355-362.
Guerena-Burgueno, P., Benenson, A S., Spulveda-Amor, J.
1991 HIV-1 prevalence in selected Tijuana subpopulations. American Journal
of Public Health 81:623-625.
Guidi, Marta.
1993 Es realmente la migracion una estrategia de supervivencia?: un ejempio
and la Mixteca Alta Oaxaquena. Revista Internacional de Sociologia 3(5):
89-109. [Is migration really a survival strategy: an example of the Mixtec
and High Oaxacans. International Journal of Sociology].
Hart, A.
1995 Risky business?: men who buy heterosexual sex in Spain, H.
Brummelhuis and G. Herdt, G., eds.. Culture and Sexual Risk:
Anthropological Perspectives on AIDS. Amsterdam: Overseas Publishers
Association.
Hayes-Bautista, David.
1992 The Latino Coalition for a New Los Angeles Report. Latino Futures
Research Group, pp. 1-123.
Hayes-Bautista, D., Valdez, R. & Hurtado, B.
1994 Latino health in California, 1985-1990: implications for family medicine.
Family Medicine 26(9): 556-62.
Hobson, B.M.
1987 Uneasy Virtue: The Politics of Prostitution and the American Reform
Tradition. New York: Basic Books.
Hondagneu-Sotelo, P.
1994 Gendered Transitions: Mexican Experiences of Immigration. Los Angeles,
Ca: University of California Press.
199
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Hubell, F.A., Chavez, L.R., Mishra, S.I., Magana, J R., and Valdez, R.B.
1995 From ethnography to intervention: developing a breast cancer control
program for Latinas. Journal of the National Cancer Institute Monographs
18:109-115.
Hurtado, A., Hayes-Bautista, D., Valdez, R.B., Hernandez, A.
1992 Redefining California: Latino Social Engagement in a Multicultural
Society. UCLA: Chicano Studies Research Center.
Karno, M. and Edgerton, R.B.
1969 Perception of mental illness in a Mexican American community. Archives
of General Psychiatry 20: 233-238.
Kay, M.A.
1977 Health and illness in a Mexican American barrio, IN E.H. Spicer, ed..
Ethnic Medicine in the Southwest. Tucson: University of Arizona Press.
Kennedy, D.M.
1996 Can we still afford to be a generation of immigrants? The Atlantic Monthly
278: 52-68.
Kiev, A.
1968 Curanderismo: Mexican American Folk Psychiatry. New York: The Free
Press.
Kemper, R.V.
1979 Frontiers in migration: from culturalism to historical structuralism in the
study of Mexico-U.S. Migration, IN F. Camara and R.V. Kemper, eds..
Migration Across Frontiers: Mexico and the United States. Institute for
Mesoamerican Studies. Sate University of New York.
Kleinman, A. and Kleinman, J.
1996 The appeal of experience: the dismay of images: cultural appropriations of
suffering in our times. Daedelus 125(1): 1-24.
Kondo, Dorrine, K.
1990 Crafting Selves: Power, Gender and Discourses of Identity in a Japanese
Workplace. Chicago: University of Chicago Press.
Krueger, R.A.
1988 Focus Groups: A Practical Guide for Applied Research. London: Sage
Publications.
Lewis, O.
1966 La Vida. New York: Vintage Books.
200
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Lock, M.
1993 Cultivating the body: anthropology and epistemologies of bodily practice
and knowledge. Annual Review of Anthropology 22: 133-155.
Los Angeles County
1996 Overview of the Los Angeles County Health Crisis. Los Angeles, CA: Los
Angeles County Department of Health and Human Services, June
Publication.
Los Angeles Times.
1998 Gun deaths of children rise. August 8, B1-B6.
Madsen, William.
1961 Society and Health in the Lower Rio Grande Valley. Austin, Texas: Hogg
Foundation for Mental Health.
1964 Mexican Americans of South Texas, ed. 1. New York: Holt, Rinehart &
Winston.
Mackling, June.
1978 Curanderismo and espiritismo: complementary approaches to traditional
mental health services, IN B. Velimirovic, ed.. Modern Medicine and
Medical Anthropology in the United States-Mexican Border Population.
Washington, D C.: Pan American Health Organization, Scientific
Publication No.359.
1980 All the good and the bad in this world: women, traditional medicine, and
Mexican American culture, IN M. B. Melville, ed.. Twice a Minority:
Mexican American Women. St. Louis: The C.V. Mosby Company.
Magana, J R., De la Rocha, O., Amsel, J.
1996 Sexual history and behavior of Mexican immigrant workers in Orange
County, California, IN S.l Mishra, R.F. Conner, and R.J. Magana, eds.,
AIDS Crossing Borders: The Spread of HIV among Migrant Latinos.
Boulder, CO: Westview Press.
Magana, J.R.
1991 Sex, drugs, and HIV: an ethnographic approach. Social Science and
Medicine 33: 5-9.
Magana, J.R. and Carrier, J.M.
1991 Mexican and Mexican American male sexual behavior and the spread of
AIDS in California. Journal of Sex Research (28) 3: 425-441.
201
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Magana, J R., Ferreira-Pinto, J.B., Blair, M., Mata, A.
1992 Una pedagogia de conscientizacion para la prevencion del VIH/SIDA.
Revista Lainoamericana de Psicologia 24:97-108.
Magana, J.R. and Magana, H.A.
1980 An experimental approach to the study of parental values. Paper
presented at the ninth annual meeting for the Society for Cross-Cultural
Research, February.
Manzanedo, H.G., Walters, E.G., and Lorig, K.R.
1980 Health and illness perceptions of the Chicana, IN B. M. Melville, ed..
Twice a Minority: Mexican American Women. St. Louis: The C.V. Mosby
Company.
Marin, B.V.
1995 Analysis of AIDS prevention among African Americans and Latinos in the
US. Report prepared for the office of Technology Assessment.
Marks, G., Cantero, P.J., & Simoni, J.M.
1998 Is acculturation associated with sexual risk behaviors? An investigation of
HIV-Positive Latino men and women. AIDS Care 10(3):283-295.
Mays, V. & Cochran, S.
1988 Issues in the perception of AIDS risk and risk reduction activities by Black
and Hispanic/Latina women. American Psychologist 43: 949-957.
McKeganey, N.P.
1994 Prostitutes and HIV: what do we know and where might research be
targeted in the future. AIDS 1994 8: 1215-26.
Melville, M.B.
1980 Twice a Minority: Mexican American Women. St. Louis: C.V. Mosby.
1980 Selective acculturation of female Mexican Migrants, IN M.B. Melville, ed..
Twice a Minority: Mexican American Women. St. Louis: C.V. Mosby.
Mishra, S.l. and Conner, R.F.
1996 Evaluation of an HIV prevention program among Latino farm workers, IN
S.l Mishra, R.F. Conner, and R.J. Magana, eds., AIDS Crossing Borders:
The Spread of HIV among Migrant Latinos. Boulder, CO: Westview
Press.
Mishra, S., Conner, R., and Magana, J.R. eds.
1996 Migrant workers in the US: a profile from the fields, IN AIDS Crossing
Borders, The Spread of HIV among Migrant Latinos. Boulder, Co:
Westview Press.
202
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Miller, H.G., Turner, C.F., and Moses, LE. eds.
1990 AIDS the Second Decade. Washington, D.C.: National Academy Press.
Modiano, Manuel, R.
1995 Breast and cervical cancer In Hispanic women. Medical Anthropologist
Quarterly 9(1): 75-79.
Moe, A., McGee-Smlth, D., Dematls, K., Wyatt, G.
1998 Cervical dysplasia progression rates over 1 and HIV testing by
gynecologists In a cohort of HIV-Infected women In Los Angeles.
Montlel, M.
1970 The social science myth of the Mexican American family. El GrIto 3: 56-
63.
Moore, A.
1992 Cultural Anthropology: The Field Study of Human Beings. San Diego: The
Collegiate Press.
Morgan, D.L.
1988 Focus Groups as Qualitative Research. London: Sage Publications.
1993 Successful Focus Groups: Advancing the State of the Art. London: Sage
Publications.
Morse, J.M.
1994 Designing funded qualitative research, IN N. Denzin and Y. LIncon, eds..
Handbook of Qualitative Research. Thousand Oaks, Ca: Sage
publications.
1992 Qualitative Health Research. London: Sage Publications.
Morsey, S.
1990 Political economy In medical anthropology, IN T.M. Johnson and C.F.
Sargent, eds.. Medical Anthropology: A Handbook of Theory and Method.
New York: Greenwood Press.
Moustafa, A T. and Weis, G.
1968 Health Status and Practices of Mexican Americans. Study Project
Advance Report NO. 11. University of California Los Angeles Graduate
School of Business Administration.
Nall, F.C. and Spielberg, J.
1967 Social and cultural factors In the responses of Mexican Americans to
medical treatment. Journal of Health and Social Behavior 8:299-308.
203
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Nix, H.L.
1978 The community and its involvement in the study planning action process.
(HEW Publication No. CDC 78-8355). Washington, DC: Government
Printing Office.
Nordstrom, C.
1998 Terror warfare and the medicine of peace. Medical Anthropology Quarterly
12(1): 10- 121.
Odegard, O.
1946 A statistical investigation of the incidence of mental disorders in Norway.
Psychiatry Quarterly 20: 382-383.
Ortner, S.
1994 Culture, Power, and History. Princeton: Princeton University Press.
Organista, K.C. and Balls-Organista, P
1997 Migrant laborers in the US: a review of the literature. AIDS Education and
Prevention 9(1): 83-93.
O’Reilly, K. and Higgins, D.
1991 AIDS community demonstration projects for HIV prevention among hard to
reach groups. Public Health Reports 106:714-20.
Radian, N.S., Shiboski, S.C. and Jewell, N.P.
1991 Female-to-male transmission of human immunodeficiency virus. JAMA
266:1664-1667.
Paredes, Americo.
1978 On ethnographic work among minority groups: a folklorist perspective, IN
R. Romo and R. Paredes, eds., New Directions in Chicano Scholarship.
Chicano Studies Monographs Series. La Jolla: University of California,
San Diego, Chicano Studies Program.
Perez, M.A. and Fennelly, K
1996 Risk factors for HIV and AIDS among Latino farm workers in
Pennsylvania, IN S.l Mishra, R.F. Conner, and R.J. Magana, eds., AIDS
Crossing Borders: The Spread of HIV among Migrant Latinos. Boulder,
CO: Westview Press.
Perkins, R.
1985 AIDS and prostitution (letter). Med. J. Aust. 143: 426.
Plot, P., Quinn, T.C., and Taleman, H.
1984 AIDS in a heterosexual population in Zaire. Lancet 2:65-69.
204
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Portes, A.
1978 Migration and underdevelopment. Politics and Society: 1-48.
1996 The New Second Generation. New York: Russell Sage Foundation.
Piore, M.J.
1979 Birds of Passage: Migrant Labor and Industrial Societies. London:
Cambridge University Press.
Polk, B.F.
1985 Female-to-male transmission of AIDS (letter). JAMA 254: 3177-3178.
Potterat, J.J., Muth, J.B. and Markewich, G.S.
1986 Serological markers as indicators of sexual orientation in AIDS virus-
infected men (letter). JAMA 256: 712.
Pyett, P. and Warr, D.
1997 Vulnerability on the streets: female sex workers and AIDS. AIDS Care
9:539-47.
Quesada, J.
1997 Suffering the winds of Lhasa: politicized bodies, human rights, cultural
differences and humanism in Tibet. Medical Anthropology Quarterly
12(1): 51-73.
Redfield, R.R., Markham, P.D., Salahuddin, S.Z., Wright, D.C_, Sarngadharan,
M.G., and Gallo, R.C.
1985 Heterosexually acquired HTLV-III/LAV disease: epidemiologic evidence
for female-to-male transmission. JAMA 254:2094-2096.
Rifkin, S.B.
1988 Primary health care: on measuring participation. Social Science in
Medicine 26(9):931-940.
Roberts, J.
1999 The political economy of health: invisible genders, IN J. Cook, J. Roberts,
and G. Waylen, eds.,Towards a Gendered Political Economy. Macmillan
(forthcoming).
Roebuck, J. and McNamara, P.
1973 Ficheras and free-lancers: prostitution in a Mexican border city. Archives
of Sexual Behavior 2(3): 231-244.
Rojas, A.
1997 Most Mexicans don't stay in the US. The San Francisco Chronicle, p.3.
205
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Romano, Octavio.
1965 Charismatic medicine, folk healing, and folk sainthood. American
Anthropologist 67: 1151-1173.
Rosenberg, M.J., Weiner, J.M.
1988 Prostitutes and AIDS: a health department priority. Am. J. of Public
Health. 78:418-23.
Rubel, Arthur. J.
1966 Across the tracks: Mexican Americans in a Texas City. Austin, Texas:
Hogg Foundation.
Rubel, R.J. and Garro, L.C.
1992 Social and cultural factors in the successful control of tuberculosis. Public
Health Reports 107: 626-637.
Rumbaut, R.G.
1996 The crucible within ethnic identity, self-esteem, and segmented
assimilation among children of immigrants, IN A. Portes, éd.. The New
Second Generation. New York: Russell Sage Foundation.
Salgado de Snyder, N.V.
1994 Mexican women, mental health, and migration: those who go and those
who stay behind, IN R. Malgady, and O. Rodriguez, eds.. Theoretical and
Conceptual Issues in Hispanic Mental Health. Malabar, Florida: Krieger
Publishing Company.
Salgado de Snyder, N.V., Perez, M.J, Maldonado, M.
1998 AIDS: risk behaviors among rural Mexican women married to migrant
workers in the United States. AIDS Education and Prevention 8(2): 134-
143.
Sassen, S.
1988 The Mobility of Labor and Capital. Cambridge: Cambridge University
Press.
Saunders, Lyle.
1954 Cultural differences in medical care: the case of the Spanish-speaking
people of the Southwest. New York: Russell Sage Foundation.
Sargent, C.F. and Brettell, C.B., eds.
1999 Gender and Health: An International Perspective. Upper Saddle River,
NJ: Prentice-Hall.
206
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Schepper-Hughes, N. and Lock, M.
1987 The mindful body: a phlegomenon to future work in medical anthropology.
Medical Anthropology Quarterly 1(1): 6-41.
Schepper-Hughes, N.
1992 Death without Weeping: The Violence of Everyday Life in Brazil. Berkley:
University of California Press.
1996 Small wars and invisible genocides. Social Science and Medicine 43(5):
889-900.
Shedlin, M.G.
1993 Prostitution and HIV risk behavior. Advances in Population: Psychosocial
Perspectives 1: 157-72.
1987 If you want to kiss, go home to your wife: sexual meanings for the
prostitute and implications for AIDS prevention activities. Paper presented
at the Annual Meeting of the American Anthropological Association,
Chicago.
Schwebbel, A.
1973 A community organization approach to the implementation of
comprehensive planning. American Journal of Public Health 63.
Singer, M.
1992 AIDS and US ethnic minorities: the crisis and alternative anthropological
responses. Human Organization 51(1): 89-95.
1995 Beyond the ivory tower: critical praxis in medical anthropology. Medical
Anthropology Quarterly 9(1): 80-106.
1996 Farewell to adaptionism: unnatural selection and the politics of biology.
Medical Anthropology Quarterly 10(4): 496-515.
Skjerdal, K, Mishra, S.L, & Benavides-Vaello, S.
1996 A growing HIV/AIDS crisis among migrant and seasonal farm worker
families IN S.l. Mishra, R. F. Conner, and R.J. Magana, eds., AIDS
Crossing Borders: The Spread of AIDS among Migrant Latinos. Boulder,
Co: Westview Press.
Sobo, E.J.
1995 Choosing Unsafe Sex: AIDS Risk Denial among Disadvantaged Women.
Philadelphia: University of Pennsylvania Press.
207
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Tesch, R.
1990 Qualitative Research: Analysis Types and Software Tools. London: Sage
Publications.
Tienda, M.
1983 Residential distribution and internal migration patterns of Chicanos: a
critical assessment, IN A. Valdez, A. Camarillo and T. Almaguer, eds..
The State of Chicano Research in Family: Labor and Migration Studies.
Stanford Center for Chicano Research.
United Way.
1997 State of the County Data Book Los Angeles 1996-97. Los Angeles, CA:
United Way of Greater Los Angeles.
Urdaneta, Maria Luisa.
1980 Chicana use of abortion: the case of Alcala, IN B, M. Melville, ed.. Twice a
Minority: Mexican American Women. St. Louis: The C.V. Mosby
Company.
Uzzell, D.
1976 Ethnography of migration: breaking out of the bipolar myth, IN D. Quillet
and D. Uzzell, eds.. New Approaches to the Study of Migration. Houston,
Texas, Rice University Studies.
Valdez, R.B., Giachello, A., Rodriguez-Trias, H., Gomez, P. & De la Rocha, C.
1993 Improving access to health care in Latino communities. Public Health
Reports 108(5): 534-539.
Valdez, R.B., Morgenstern, H., Brown, R, Wyn, R., Wang, C., & Cumberland, W.
1993 Insuring Latinos against the cost of illness. Journal of the American
Medical Association 269(7): 889-894.
Velez-lbanez, Carlos, G.
1980 The nonconsenting sterilization of Mexican women in Los Angeles: issues
of psychocultural rupture and legal redress in paternalistic behavioral
environments, IN B.M. Melville, ed.. Twice a Minority: Mexican American
Women. St. Louis: The C.V. Mosby Company.
Vega, W.A., Bohdan, K., Aguilar-Gaxiola, S., Alderete, E., Catalano, R. &
Caraveo-Anduaga, J.
1998 Lifetime prevalence of DMS lll-R psychiatric disorders among urban and
rural Mexican Americans in California. Archives of General Psychiatry 55
(9): 771-778.
208
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Vera, M., Alegria, M., Santos, M., and Burgos, M.
1993 Depressive symptoms and HIV risk taking behaviors among adolescent
and adult Hispanic sex workers: Implications for HIV risk reduction
strategies. International Conference on AIDS 9(2): 898, abstract no. PO-
D22-4080, June 6-11.
Ward, M.
1993 A different disease: HIV/AIDS and health care for women In poverty.
Culture, Medicine, and Psychiatry 17(4).
Weaver, J.L.
1969 Health Care Service Use In Orange County, California: A Socioeconomic
Analysis. Long Beach Center for Political Research, Ca. State University.
Weller, Susan, Lee Pachter, Robert Trotter, and Roberta Baer.
1993 Empacho In four Latino groups: a study of Intra- and Inter-cultural variation
In beliefs. Medical Anthropology Quarterly 15: 109-136.
Wood, H.C.
1982 Equilibrium and historical structural perspectives on migration.
International Migration Review 16: 298-319.
Wyatt, G., Srinlvasan, S., Axelrod, J., Tucker, B., Romero, B., MItchell-Kernan, C.
1996 Aftermath of HIV diagnosis among women: psychosocial consequences.
Int. Conf. AIDS 11(2):417 (abstract no. Th.D.5069) Jul 7-12.
Zavella, Patricia.
1982 Recording Chicana life histories: refining the Insiders perspective IN E.
Jameson, ed., Insider/Outsider Relationships with Informants. Southwest
Research Institute on Women, Working Paper No 13:13-24.
Zambrana, R.E., Scrimshaw. S.C., Collins, N. and Dunket-Schetter, C.
1997 Prenatal health behaviors and psychosocial risk factors In pregnant
women of Mexican origin: the role of acculturation. Am J Public Health
87:1022-1026.
209
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Appendix A: Biographical Profiles (Pseudonyms)
The total of forty interviews consisted of twenty female and twenty male
immigrants. One hundred percent of the women were Mexican-born. The ethnic
composition of the men varied; 90% were from Mexico and the other 10% from
Central America. Of the women, the youngest was 19 and the oldest 39. Of the
men the youngest was 18 and the oldest 60. The chart below shows the
numerical distribution according to gender, age, and life stage.
Life
Stage
Age (years)
Youngest
(18-24)
Middle
(20-40)
Oldest
(40 and above)
N= 40
Women (20) 10 10 0
Men (20) 5 15 6
This chart shows that a significant number (95%) of women were of reproductive
age. In the biographical sketches that follow, I indicate the life stage by age. I
used pseudonyms to protect the participant’s identity.
Females
1. Maria del Carmen Almaraz
She is 30 years old, was born in Mexico, has lived in the US for six months, and
speaks only Spanish. She is Roman Catholic, has no formal education, and
separated from her husband of five years. She lives with her 3 children and
boyfriend. She has an annual income of $600 per month from sex work, waiting
on tables at a local cantina, and selling tamales. She never worked as sex
worker in Mexico and her primary occupation was that of a homemaker.
2. Rosa Maria Almeida
She is 34 years old, was born in Mexico and has lived in the US for 1 month.
She speaks only Spanish, is a Roman Catholic and completed the grade.
She is divorced and lives with a family of five who are not her relatives. Her five
children live in Mexico with her mother. She makes $500 per month from sex
work and cleaning homes. She never worked as a sex worker in Mexico and her
primary occupation was that of a waitress in a coffee shop.
3. Juana Armendariz
She is 19 years old, was born in Mexico and has lived in the US for 12 years.
She speaks both English and Spanish, is a Roman Catholic and completed the
8 **’ grade. She has never been married and lives with her sister, her brother
and her mother. She makes $1200 per month from sex work and selling drugs.
210
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
She never worked as a sex worker In Mexico and her primary occupation was
that of student.
4. Ana Araujo
She Is 39 years old, was born In Mexico and has lived In the US for 4 months.
She speaks Spanish only, Is a Chrlstlan-Pentecostal, and completed the
grade. She has never been married and lives with three female roommates
who are not her relatives. She makes $1200 per month from sex work. She
never worked as a sex worker In Mexico and her primary occupation was that of
homemaker.
5. Sofia Azalea
She Is 31 years old, was born In Mexico and has lived In the US for 2 years. She
speaks Spanish only. Is Roman Catholic, and completed the 3rd grade. She Is
separated and lives with her friend and her family. She makes $700 per month
from sex work and selling women’s clothes. She never worked as a sex worker
In Mexico and her primary occupation was that of homemaker
6. Dolores Baca
She Is 27 years old, was born In Mexico and has lived In the US for 1 year. She
speaks Spanish only. Is Roman Catholic, and completed the 5th grade. She Is
separated and lives with her male friend and his family. She makes $700 per
month from sex work, cleaning houses, and waiting on tables at a cantina. She
never worked as a sex worker In Mexico and her primary occupation was that of
homemaker
7. Gloria Blanco
She Is 21 years old, was born In Mexico and has lived In the US for 3 years. She
speaks Spanish only. Is Roman Catholic, and completed the 2nd grade. She Is
single and lives with her female friend and her family. She makes $700 per
month from sex work and waiting on tables at a coffee shop during the day. She
never worked as a sex worker In Mexico and her primary occupation was that of
domestic worker.
8. Luplta Daleslo
She Is 26 years old, was born In Mexico and has lived In the US for 6 months.
She speaks Spanish only. Is Roman Catholic, and completed the 4th grade.
She Is single and lives with two female roommates. She makes $700 per month
from sex work and waiting on tables at a cantina. She never worked as a sex
worker In Mexico and her primary occupation was that of domestic worker.
9. Luz Damian
She Is 20 years old, was born In Mexico and has lived In the US for 2 years. She
speaks Spanish only. Is Roman Catholic, and completed the 9th grade. She Is
single and lives with two female roommates and their children. She makes $500
per month from sex work and selling music tapes as a street vendor. She never
211
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
worked as a sex worker in Mexico and her primary occupation was that of
student at a beauty school.
10. Angela Casas
She is 38 years old, was born in Mexico and has lived in the US for 5 years. She
speaks Spanish only, is Roman Catholic, and completed the 7th grade. She is
divorced and lives with her two children and 3 other relatives. She makes $1200
per month from sex work and selling women's under-ware. She never worked as
a sex worker in Mexico and her primary occupation was that of homemaker.
11. Andrea Castor
She is 28 years old, was born in Mexico and has lived in the US for 3 years. She
speaks Spanish only, is Roman Catholic, and completed the 11th grade. She is
divorced and lives with her two children and 2 other relatives. She makes $1400
per month from sex work. She never worked as a sex worker in Mexico and her
primary occupation was that of domestic worker.
12. Marta Lujan
She is 20 years old, was born in Mexico and has lived in the US for 2 years. She
speaks both English and Spanish, is Roman Catholic, and completed the 6th
grade. She is single and lives with her sister and 2 other distant relatives. She
makes $700 per month from sex work and selling women’s clothes. She never
worked as a sex worker in Mexico and her primary occupation was that of
student.
13. Maria Lagos
She is 24 years old, was born in Mexico and has lived in the US for 2 years. She
speaks Spanish only, is Roman Catholic, and completed the 10th grade. She is
separated and lives with her two female roommates who are not related to her.
She makes $1000 per month from sex work and waiting tables at a cantina. She
never worked as a sex worker in Mexico and her primary occupation was that of
waitress.
14. Tereza Perez
She is 22 years old, was born in Mexico and has lived in the US for 8 months.
She speaks Spanish only, is Roman Catholic, and completed the 6th grade.
She is single and lives with her female roommate and her children. She makes
$800 per month from-sex work and waiting on tables at a restaurant during the
day. She never worked as a sex worker in Mexico and her primary occupation
was that of domestic worker.
15. Laura Perez
She is 33 years old, was born in Mexico and has lived in the US for 2 years. She
speaks Spanish only, is Roman Catholic, and completed the 6th grade. She is
divorced and lives with her two female roommates who are not related to her.
She makes $1200 per month from sex work and waiting on tables at a cantina.
212
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
She never worked as a sex worker in Mexico and her primary occupation was
that of domestic worker.
16.Lica Sainz
She is 22 years old, was born in Mexico and has lived in the US for 1 year. She
speaks Spanish only, she claims no religion, and completed the 6th grade. She
is single and lives with a male roommate and his family of five. She makes $900
per month from sex work, cleaning homes, and waiting on tables at a cantina.
She never worked as a sex worker in Mexico and her primary occupation was
that of food clerk.
17. Laura Soto
She is 21 years old, was born in Mexico and has lived in the US for 6 months.
She speaks Spanish only, is Roman Catholic, and completed the 8th grade.
She is single and lives with her two female friends. She makes $700 per month
from sex work and waiting on tables at a restaurant during the day. She never
worked as a sex worker in Mexico and her primary occupation was that of
domestic worker.
18. Marcela Sotomayor
She is 33 years old, was born in Mexico and has lived in the US for 2 months.
She speaks Spanish only, is Roman Catholic, and completed the 6th grade.
She is separated and lives with her two children and 2 other relatives. She
makes $900 per month from sex work. She never worked as a sex worker in
Mexico and her primary occupation was that of domestic worker.
19. Alva Tapia
She is 21 years old, was born in Mexico and has lived in the US for 1 year. She
speaks both English and Spanish, is Roman Catholic, and completed the 6th
grade. She is single and lives with a male friend and his family of four. She
makes $1000 per month from sex work. She never worked as a sex worker in
Mexico and her primary occupation was that of domestic worker.
20. Sofia Torres
She Is 25 years old, was born in Mexico and has lived in the US for 1.4 years.
She speaks Spanish only, is Roman Catholic, and completed the 8th grade.
She is separated and lives with her two children and four other relatives. She
makes $600 per month from sex work. She never worked as a sex worker in
Mexico and her primary occupation was that of factory worker.
MALES
1. Octavio Acuna
He is 40 years old. He was born in Mexico and has lived in the US for 2 years.
He speaks only Spanish and is a Roman Catholic. He completed the 6‘^ grade,
is married but not currently living with spouse who resides in Mexico. He lives
with 4 other male relatives in a one-bedroom apartment. He earns $600 per
213
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
month working as a day laborer. He reported his health to be good but had no
health insurance or a regular doctor.
2. Ramon Aceves
He is 31 years old. He was born in Mexico and has lived in the US for 9 months.
He speaks only Spanish and is a Roman Catholic. He completed the grade
and has never been married. He lives with a brother and a sister and their
families in a two-bedroom apartment. He earns about $600 per month working
as a construction worker. He reported his health to be good but had no health
insurance or a regular doctor.
3. Raul Ayala
He is 21 years old. He was born in Mexico and has lived in the US for 3.5 years.
He speaks only Spanish and is a Roman Catholic. He completed the 12‘* ’ grade
and has never been married. He lives alone in his own studio apartment. He
earns about $1,500 per month working as a day laborer. He reported his health
to be good but had no health insurance or a regular doctor.
4. Angel Andrade
He is 60 years old. He was born in Mexico and has lived in the US for 42 years.
He speaks only Spanish and is a Roman Catholic. He did not attend school at all
and did not know how to read or write. He lives with his daughter and sees his
wife, who lives in Mexico, about every two years. He earns about $500 per
month working as a day laborer performing low-skill jobs. He reported his health
to be fair as he was suffering from diabetes, had no insurance or a regular
doctor.
5. Roman Bajio
He is 51 years old. He was born in Mexico and has lived in the US for 3 years.
He speaks only Spanish and is a Roman Catholic. He completed the first grade
but did not know how to read or write. He lives with his boss who rented him a
room in his house. He did not have a job at the time because he was disabled.
He reported his health to be fair as he was suffering from diabetes and had no
insurance or a regular doctor.
6. Alberto Busto
He is 20 years old. He was born in Mexico and has lived in the US for 3 years.
He speaks Spanish and some English and reported being Roman Catholic. He
completed the 6th grade and wanted to attend college some day. He was single
and living with non-relatives. He reported making $600 per month as a day
laborer and performing mostly construction work. He stated being in good health
but had no insurance or a regular doctor.
7. Daniel Lamas
He is 39 years old. He was born in Mexico and has lived in the US for six
months. He speaks only Spanish and reported being Roman Catholic. He
214
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
completed the 8th grade and wanted to attend trade school to become an
electrician. He was widowed having lost his wife to cancer two years ago. He
lived with his brothers and sisters who helped him cope with the loss of his wife.
He reported making $600 per month as a construction worker. He stated being
in good health but had no insurance or a regular doctor
8. Jose Lara
He is 46 years old. He was born in Mexico and has lived in the US for 4 years.
He speaks only Spanish and reported being Roman Catholic. He completed the
8th grade and wanted to have his own business as a taxi driver. He was married
but his wife resided in Mexico. He had not seen his wife for four years since he
moved to the US. He lived with his brothers and non-related roommates. He
reported making $960 per month as a construction worker. He stated being in
good health but had no insurance or a regular doctor
9. Juan Macias
He is 36 years old. He was born in Mexico and has lived in the US for 1 year. He
speaks only Spanish and reported being Roman Catholic. He completed the 6th
grade and wanted to attend trade school to learn plumbing. He was married but
his wife resided in Mexico. He had not seen his wife for a year since he moved
to the US. He lived with a family who were not relatives and rented him a room.
He reported making $600 per month as a construction worker. He stated being
in good health but had no insurance or a regular doctor
10. Jesus Magana
He is 37 years old. He was born in Mexico and has lived in the US for 2 years.
He speaks only Spanish and reported being Roman Catholic. He completed the
10th grade. He was married but his wife resided in Mexico. He had not seen his
wife or his four children for 2 years since he moved to the US. He lived with his
brother and sister and 3 other non-relatives in a two-bedroom apartment. He
reported making $800 per month as a construction worker. He stated being in
good health but had no insurance or a regular doctor
11. Alberto Moreno
He is 24 years old. He was born in El Salvador and has lived in the US for 2
years. He speaks only Spanish and reported being Roman Catholic. He
completed the 8th grade. He had never been married. He lived with 3 non
relatives in a one-bedroom apartment. He made $600 per month selling music
cassette tapes on the street. He reported being in good health but had no
insurance or a regular doctor.
12. Raul Mungia
He is 47 years old. He was born in Mexico and has lived in the US for 3 years.
He speaks only Spanish and reported being Roman Catholic. He completed the
10th grade. He was married and his wife resided in Mexico. He lived with his 2
siblings and 3 other relatives in a two-bedroom apartment. He made $1200 per
215
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
month as a gardener for a large hotel. He reported being in fair health as he
suffered from diabetes but had no insurance or a regular doctor
13. Arturo Solis
He is 30 years old. He was born in Mexico and has lived in the US for 3 years.
He primarily speaks Spanish and some English. He reported being Roman
Catholic. He completed the 10th grade. He was married but was separated from
his wife who resided in Mexico. He lived with his 2 siblings and 3 other relatives
in a two-bedroom apartment. He made $800 per month as an independent
gardener. He reported being in good health but had no insurance or a regular
doctor
14. Marvin Sorto
He is 22 years old. He was born in Mexico and has lived in the US for 2 years.
He primarily speaks Spanish and some English. He reported being Roman
Catholic. He completed the 9th grade. He had never been married. He lived
with two non-relatives in a one-bedroom apartment. He made $800 per month
installing dry wall. He reported being in good health but had no insurance or a
regular doctor
15. Juan Jose Tapia
He is 28 years old. He was born in El Salvador and has lived in the US for 2
months. He speaks Spanish only. He reported being Christian-Pentecostal. He
completed the 6th grade. He had never been married. He lived with three non
relatives in a one-bedroom apartment. He made $500 per month as an
independent gardener. He reported being in good health but had no insurance or
a regular doctor
16. Roberto Topaz
He is 45 years old. He was born in Mexico and has lived in the US for 5 years.
He speaks both Spanish and English. He reported being Roman Catholic. He
completed the 6th grade. He was married and living with his wife of 14 years.
He lived in a one-bedroom apartment with his wife and children and other
relatives. He made $1400 per month installing dry wall. He reported being in
good health but had no insurance or a regular doctor
17. Ricardo Urdaneta
He is 43 years old. He was born in Mexico and has lived in the US for 2 years.
He speaks Spanish better than English. He reported being Roman Catholic. He
completed the 6th grade. He was divorced and had not seen his four children
since he moved to the US. He lived in a one-bedroom apartment with his brother
and sister and one other relative. He made $1000 per month working as a
gardener. He reported being in good health but had no insurance ora regular
doctor
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
216
18. Ramon Valdez
He is 38 years old. He was born in Mexico and has lived in the US for 3 years.
He speaks Spanish better than English. He reported being Roman Catholic. He
completed the 6th grade. He was married but had not seen his wife and four
children since he moved to the US because they lived in Mexico. He lived in a
one-bedroom apartment with his sister and her three children. He made $1200
per month working as a construction worker. He reported being in good health
but had no insurance or a regular doctor
19. Saul Vasquez
He is 35 years old. He was born in Mexico and has lived in the US for 6 months.
He speaks only Spanish. He reported being Roman Catholic. He completed the
5th grade. He was divorced and had three children who lived in Mexico with his
ex-wife. He lived with three males who were not related to him. He made $600
per month working as a day laborer. He reported being in good health but had
no insurance or a regular doctor.
20. Douglas Vives
He is 19 years old. He was born in Mexico and has lived in the US for 1 year. He
speaks only Spanish. He reported not belonging to any religion. He completed
the 11th grade. He had never been married. He lived with two of his brothers in
a studio apartment. He made $700 per month working as a day laborer. He
reported being in good health but had no insurance or a regular doctor.
217
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Appendix B:........... STUDY QUESTIONNAIRE
1. Participant ID Number:
2. Date of Interview: / /
3. Begin time: AM/PM
4. Study population: WOMEN....................... 01
MEN.............................02
5. Source of recruitment of participant
SECTION A :..........................DEMOGRAPHICS
6. (RECORD SEX AS OBSERVED):
MALE..................................................................01
FEMALE............................................................ 02
UNDETERMINED............................................. 03
7. First, are you male or female?
MALE..................................................................01
FEMALE............................................................ 02
8. What is your date of birth? / /
9. Where were you born?
MEXICO............................................................. 01
EL SALVADOR................................................. 02
HONDURAS......................................................03
COLOMBIA........................................................ 04
CUBA..................................................................05
SPECIFY OTHER.............................................06
10. How many years have you lived in the United States?
11. What was the language that you used as a child?
SPANISH ONLY............................................... 01
SPANISH MORE THAN ENGLISH.................02
BOTH EQUALLY.............................................. 03
ENGLISH MORE THAN SPANISH...............04
ENGLISH ONLY..............................................05
12. What languages do you read and speak now?
SPANISH ONLY..............................................01
SPANISH BETTER THAN ENGLISH............02
BOTH EQUALLY WELL................................... 03
ENGLISH BETTER THAN SPANISH............04
ENGLISH ONLY..............................................05
218
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
13. What language do you usually speak at home?
SPANISH O N LY............................................... 01
SPANISH MORE THAN ENGLISH................ 02
BOTH EQUALLY.............................................. 03
ENGLISH MORE THAN SPANISH................ 04
ENGLISH O NLY............................................... 05
14. In which language do you usually think?
SPANISH O NLY............................................... 01
SPANISH MORE THAN ENGLISH................ 02
BOTH EQUALLY.............................................. 03
ENGLISH MORE THAN SPANISH................ 04
ENGLISH ONLY............................................... 05
15. What language do you usually speak with your friends?
SPANISH O N LY............................................... 01
SPANISH MORE THAN ENGLISH................ 02
BOTH EQUALLY.............................................. 03
ENGLISH MORE THAN SPANISH................ 04
ENGLISH O NLY............................................... 05
16. What is your religion?
17. What is the last grade or year that you completed in school?
NONE. NO FORMAL SCHOOLING................................................... 00
PRIMARY/ELEMENTARY..................................... 01 02 03 04 05 06
JUNIOR HIGH..................................................................................07 08
HIGH SCHOOL/GED 09.10 11 12
COLLEGE/TECHNICAL SCHOOL YEARS 13 14 15 16
GRADUATE/PROFESSIONAL........................................................... 17
18. Are you currently married, separated, divorced? widowed, or have you ever
been married?
MARRIED.......................................................... 01
SEPARATED.....................................................02
DIVORCED .......................................................03
WIDOWED......................................................... 04
NEVER MARRIED............................................05
19. Are you currently living together with (your spouse/partner?)
N O ......................................................................01
YES.....................................................................02
219
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
20. Where do you live now?
IN MY OWN HOME OR MY OWN APARTMENT............................01
IN MY FAMILY'S HOME OR APARTMENT......................................02
IN SOMEONE ELSE'S HOME OR APARTMENT (NOT FAMILY) 03
IN A ROOMING HOUSE OR A SINGLE ROOM HOTEL................04
IN A WELFARE HOTEL.......................................................................05
IN A SHELTER.....................................................................................06
IN A HALFWAY HOUSE......................................................................07
IN A GROUP HOME............................................................................ 08
IN AN INSTITUTION............................................................................ 09
ON THE STREET (PARK, STEAMVENT, DOORWAY, ETC.) 10
OTHER (SPECIFY)...............................................................................11
21. Does anyone else live there with you?
N O ...................................................................... 01
YES..................................................................... 02
22. (IF YES) Who else lives there? (PROBE: anyone else?)
(SELECT ALL THAT APPLY)
ONE OR BOTH PARENTS................................................................. 01
AN ADULT GUARDIAN (OTHER THAN PARENT)......................... 02
ONE OR MORE BROTHERS AND/OR SISTERS........................... 03
OTHER RELATIVE(S)..........................................................................04
FOSTER PARENT/FAMILY................................................................ 05
SPOUSE................................................................................................06
RESPONDENT'S CHILDREN.............................................................07
OTHER CHILDREN............................................................................. 08
NONSPOUSE SEX PARTNER...........................................................09
ROOMMATE(S) (NON-RELATED, NON-SEX PARTNERS) 10
OTHER (SPECIFY: )............................................................11
23. How long have you lived there?__________________
24. (IF LESS THAN ONE MONTH) Where did you live before that?
IN MY OWN HOME OR APARTMENT..............................................01
IN MY FAMILY'S HOME OR APARTMENT......................................02
IN SOMEONE ELSE'S HOME OR APARTMENT (NOT FAMILY) 03
IN A ROOMING HOUSE OR A SINGLE ROOM HOTEL................04
IN A WELFARE HOTEL.......................................................................05
IN A SHELTER.....................................................................................06
IN A HALFWAY HOUSE..................................................................... 07
IN A GROUP HOME............................................................................ 08
IN AN INSTITUTION............................................................................ 09
ON THE STREET (PARK, STEAM VENT, DOORWAY, ETC) 10
OTHER (SPECIFY: )............................................................ 11
220
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
25. How do you get your source(s) of income? (PROBE: Any others?)
(SELECT ALL THAT APPLY)
WAGES OR SALARY FROM JOB................................................... 01
WAGES OR SALARY FROM SPOUSE'S JOB.............................. 02
FRIENDS/FAMILY/SEXUAL PARTNER..........................................03
CHILD SUPPORT.............................................................................. 04
DISABILITY........................................................................................ 05
WELFARE/AFDC/SSI........................................................................06
FOOD STAMPS..................................................................................07
UNEMPLOYMENT INSURANCE/WORKER'S COMPENSATION 08
SAVINGS/SELLING PERSONAL ITEMS........................................09
SEX W O R K........................................................................................ 10
OTHER (SPECIFY)............................................................................ 11
26. All together, what Is your monthly income from all these sources-that is, how
much money do you have to live on each month?
27. What was your occupation in your country of origin?
28. What is your occupation here in the USA?
SECTION B:GENERAL HEALTH AND MENTAL HEALTH
29. Would you say your health in general is excellent, very good, good fair, or
poor?
EXCELLENT.................................................... 01
VERY GOOD................................................... 02
GOOD............................................................... 03
FAIR...................................................................04
POOR............................................................... 05
30. Do you have health insurance?
N O .....................................................................01
YES....................................................................02
31. Do you have a regular doctor or a place you go to for medical checkups or
for care when you are sick?
N O ..................................................................... 01
YES.................................................................... 02
221
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
32. Have you ever stayed overnight at a hospital for treatment of mental
emotional problems, family or personal problems, or for problems with your
nerves?
NO......................................................................01 (SKIP TO 35)
YES....................................................................02
32a. (IF YES) Was that within the past 90 days?
N O .....................................................................01
YES.........................................-.......................... 02
33. Have you ever gone to a mental health counselor for mental or emotional?
problems, or for problems with for nerves (other than when you stayed overnight in
a hospital)?
NO...................................................................... 01 (SKIP TO 35)
YES.................................................................... 02
33a. (IF YES) Was that within the past 90 days?
N O .......................................... -.......................... 01
YES.................................................................... 02
34. Are you currently taking any medication prescribed by a doctor for mental?
or emotional problems, or for problems with your nerves?
N O ..................................................................... 01
YES.................................................................... 02
SECTION C: BIRTH CONTROL
35. Do you have someone who you consider your main sex partner, that is your
lover, husband, or boyfriend [wife or girlfriend]?
N O .......................................................................01
YES..................................................................... 02
36. How many times a month would you say you have sex with your main sex
partner?___________________
37. When was the last time you had sex with your main partner?___
38. During the past 90 days, that is, from (date to today), have you used any
method or device for birth control— that is, to prevent pregnancy with your main
partner?
NO........................................................................ 01 (SKIP TO 38c)
YES......................................................................02
. 222
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
38a. What method did you use most often? (Did you use any other methods?)
Most Often:______ Second:_______
DIAPHRAGM..................................................... 01
CONDOM...........................................................02
BIRTH CONTROL PILLS................................. 03
lUD.......................................................................04
DOUCHING....................................................... 05
WITHDRAWAL(PULL O U T)............................06
STERILIZATION................................................07
CONTRACEPTIVE SPONGE......................... 08
CONTRACEPTIVE FOAMS, JELLIES.
CREAMS, OR SPERMICIDE...........................09
NORPL.ANT........................................................10
OTHER METHOD.............................................. 11 (SPECIFY: )
38b. (IF YES to 38a) Did YOU or your main partner decide what
method?
to choose?
INTERVIEWEE CHOSE METHOD 01 (SKIP TO 39)
MAIN PARTNER CHOSE METHOD........................02 (SKIP TO 38d)
38c. (IF NO to 38) Are you or your partner pregnant or trying to get pregnant?
N O .......................................................................01
YES, PREGNANT............................................. 02
YES, TRYING TO GET PREGNANT............. 03
38d. Why did YOU/ not choose a method?
39. During the past 90 days, have you ever had sex with some one to get
money or drugs [with a sex worker in a cantina]?
N O .......................................................................01
YES..................................................................... 02
39a. (IF YES) With how many?__________
40. How many times a month would you say you have sex with
your clients [sex workers in cantinas]?___________________
41. When was the last time you had sex with a client [sex worker in a cantina]? _
42. During the past 90 days, that is, from (date to today), have you used any
method or device for birth control— that is, to prevent pregnancy with a client [sex
worker in a cantina]?
NO........................................................................ 01 (SKIP TO 43)
YES..................................................................... 02
223
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
42a. What method did you use most often? (Did you use any other methods?)
Most Often:_______Second:_____
DIAPHRAGM..................................................... 01
CONDOM ...........................................................02
BIRTH CONTROL PILLS..................................03
lUD.......................................................................04
DOUCHING....................................................... 05
WITHDRAWAL(PULL O U T)............................ 06
STERILIZATION................................................07
CONTRACEPTIVE SPONGE..........................08
CONTRACEPTIVE FOAMS, JELLIES,
CREAMS, OR SPERMICIDE........................... 09
NORPLANT....................................................... 10
OTHER METHOD...............................................11 (SPECIFY: )
42b. (IF YES TO 42a) Did YOU or your client [sex worker] decide what method
to choose?
INTERVIEWEE CHOSE METHOD 01 (SKIP TO 43)
SEX PARTNER CHOSE METHOD................02
42c. Why did YOU/did you not a choose method?
SECTION D: STDS
43. Have you ever had a sexually transmitted disease?
N O .......................................................................01
YES......................................................................02
44. In the past 90 days, has a doctor told you that you had any of the following
diseases? NO.......................... YES
a. Syphilis........................................................ 01..............................02
b. Gonorrhea.................................................... 01..............................02
c. Nongonnococcal Urethritis (NGU).............01..............................02
d. Chlamydia.................................................... 01..............................02
0 . Herpes (Chancroid)..................................... 01..............................02
f. Genital Warts................................................. 01..............................02
g. Some Other Specific STD That I didn't mention or that you don't remember
the Name of (SPECIFY: )......................... 01...............................02
45. (Note: This question was thrown away)
46. During the past 90 days, have you used any method or device to protect
against the spread of sexually transmitted diseases with you main sex partner?
NO.........................................................................01 (SKIP TO 47)
YES......................................................................02
224
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
46a. (IF YES) What method did you use most often?
Most Often:______Second:______
DIAPHRAGM...................................................01
CONDOM........................................................ 02
BIRTH CONTROL PILLS................................03
lUD.................................................................... 04
DOUCHING..................................................... 05
WITHDRAWAL (PULLING OUT).................. 06
STERILIZATION..............................................07
CONTRACEPTIVE SPONGE........................ 08
CONTRACEPTIVE FOAMS. JELLIES,
CREAMS, OR SPERMICIDE......................... 09
NORPLANT..................................................... 10
OTHER METHOD..............................................11 (SPECIFY: )
46b. (IF YES TO 46a) Did YOU or your main partner decide what method to
choose?
INTERVIEWEE CHOSE METHOD................................................... 01 (SKIP TO 47)
SEX PARTNER CHOSE METHOD.................................................02
46c. Why did YOU/did you not choose a choose method?
47. During the past 90 days, have you used any method or device to protect
against the spread of sexually transmitted diseases with a client [sex worker]?
NO......................................................................01 (SKIP TO 48)
YES....................................................................02
47a. (IF YES) What method did you use most often?
Most Often:________Second:______
DIAPHRAGM....................................................01
CONDOM......................................................... 02
BIRTH CONTROL PILLS................................ 03
lUD..................................................................... 04
DOUCHING......................................................05
WITHDRAWAL (PULLING OUT)................... 06
STERILIZATION...............................................07
CONTRACEPTIVE SPONGE.........................08
CONTRACEPTIVE FOAMS, JELLIES,
CREAMS, OR SPERMICIDE..........................09
NORPLANT...................................................... 10
OTHER METHOD.............................................11 (SPECIFY: )
47b. (IF YES TO 47a) Did YOU or your client [sex worker] decide what method
to choose?
INTERVIEWEE CHOSE METHOD.................01 (SKIP TO 47)
SEX PARTNER CHOSE METHOD............... 02
225
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
47c. Why did YOU/did you not choose a method?
48. Have you ever had sex when a partner used a condom?
N O ........................................................................01
YES...................................................................... 02
SECTION E: ALCOHOL AND DRUG USE
49. First, have you had any alcoholic beverages— that is, any beer, liquor, wine,
whiskey, tequila, or other drink— during the past 90 days?
NO................................................01 (SKIP TO 49a)
YES.............................................02 (SKIP TO 50)
49a. Have you ever had any alcoholic beverages at any time in your life?
N O 01 (SKIP TO 56)
YES.............................................02 (SKIP TO 56)
50. On the average, how often in the past 90 days have you had wine, beer, or
liquor-would you say every day, several times per week, or less than once per
week?
DAILY................................................................ 01
SEVERAL TIMES PER W E E K ...................... 02
ONCE PER WEEK.............................................03
LESS THAN ONCE PER W EEK..................... 04
51. On average, about how often in the past 90 days have you gotten high or
drunk on alcohol (that Is, beer, wine, or liquor)— would you say every day, several
times per week, about once per week, less than once per week, or never?
DAILY.................................................................01
SEVERAL TIMES PER W E E K ...................... 02
ONCE PER WEEK.............................................03
LESS THAN ONCE PER WEEK..................... 04
NEVER............................................................... 05 (SKIP TO 56)
52. Have you ever felt that you ought to cut down your drinking?
N O ...................................................................... 01
YES..................................................................... 02
53. Have you ever been annoyed by people criticizing your drinking?
N O ...................................................................... 01
YES..................................................................... 02
54. Have you ever felt guilty about your drinking?
N O ...................................................................... 01
YES......................................................................02
226
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
55. Have you ever had a drink first thing in the morning to steady your nerves or
get rid of a hang over?
N O ....................................................................01
YES...................................................................02
56. Now I would like to talk to you about your use of drugs. In the past 90 days,
have you used any of the following drugs? (IF NONE SKIP TO 62)
a. Marijuana or hashish.................................01
b. Sedatives or Barbiturates ("downers") 02
c. Tranquilizers (librium.valium)...................03
d. PCP (angel dust)........................................04
e. Hallucinogens (LSD, MDA)......................05
f. Nitrates or "poppers"..................................06
g. Crack or freebase..................................... 07
h. Sniffing or snorting cocaine or heroin 08
i. Inhalants (glue, aerosol sprays)............... 09
j. Amphetamines............................................ 10
k. Ectasy.......................................................... 11
57. Have you ever felt guilty about your drug use?
N O ....................................................................01
YES...................................................................02
58. Have you injected any drug on your own, without medical supervision?
NO.....................................................................01 (SKIP TO 61)
YES...................................................................02
58a. Have you injected any drug in the past 90 days?
NO.....................................................................01 (SKIP TO 60)
YES................................................................... 02
59. Thinking back over the past 90 days, have you shared needles with
someone else? By sharing needles, I mean that you used a needle and syringe
after someone else had used it?
NO..................................................................... 01 (SKIP TO 60)
YES................................................................... 02
59a. Would you say that you shared needles all the time, more than half the
time, about half the time, less than half the time or never in the past 90 days?
ALL OF THE TIME.......................................... 01
MORE THAN HALF THE TIME..................... 02
ABOUT HALF THE TIME............................... 03
LESS THAN HALF THE TIM E...................... 04
NEVER.............................................................05
227
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
60. During the past 90 days, did you ever clean your injection equipment?
NO.........................................................................01 (SKIP TO 61)
YES..................................................................... 02
60a. What did you use most frequently to clean it?
BLEACH.............................................................01
WATER ONLY...................................................02
OTHER LIQUID................................................ 03
60b. How long do you usually keep your works in the (bleach/ water/other liquid)
when you clean them?_____________
SECTION F: SEXUAL HISTORY
61. First, how old were you the first time you had vaginal or anal sex?
Age___________
[SEX LIFE IN THE LAST 90 DAYS]
62. Did you have vaginal or anal sex with anyone during the past 90 days?
N O .....................................................................01,
YES....................................................................02
63. How many people have you had sex with in the last 90 days, that is since
(date)?___________ (Number of People)
63a. How many of these partners were male, and how many females?
Males_________ Females_________
64. Now I'd like to ask you about your main sex partner with whom you have had
sex in the past 90 days. Please just give me an identifier so that I will know how
to refer to him/her.
a. GenderiMale.................................................01
Female............................................ 02
b. First sexiPast 90 days................................01
More than 90 days......................02
Now I'd like to talk with you about the kinds of sex that you've had during the past
90 days with your main partner.
65. (ASK ONLY IF R AND PARTNER ARE OF DIFFERENT GENDER) Thinking
back over the past 90 days, did you have vaginal sex with (NAME)?
NO 01 (SKIP TO 66)
YES.................................................................... 02
65a. (IF YES) How many tim es?_________ (Number of Times)
228
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
65b. Of those (NUMBER) times, did you/he ever use a condom? (IF NO, CODE
ZERO : IF YES, ASK: How tim es?)__________
(Number of Times (code 0 if "NO")
65c. Of those (NUMBER) times that you had six with (NAME), were you or
(NAME) ever high on drugs or alcohol?
N O ...................................................................... 01
YES..................................................................... 02
65d. How many times?___________________
66. During the past 90 days, did you have receptive anal sex with (NAME)?
NO 01 (SKIP TO 67)
YES..................................................................... 02
66a. (IF YES) How many times?_______
66b. Of those (NUMBERS) times, did he ever use a condom? (IF NO, CODE
ZERO; IF YES, ASK: How many times______ ?
( Number of times (code 0 if "NO")
66c. Of those (NUMBER) times that you had sex with (NAME) were you or
(NAME) ever high on drugs or alcohol?
N O ...................................................................... 01
YES..................................................................... 02
66d. How many times? ___________
67. We've been talking about your main partner. Now I'd like to ask you
some questions about your clients [sex workers] you had sex with in
the past 90 days. First, did you have vaginal sex with any of these
partners?
NO........................................................................ 01 (SKIP TO 68)
YES..................................................................... 02
67a. (IF YES) All together, how many times?________
67b. Of those (NUMBER) times, did you or your partner ever use a
condom? (IF NO, CODE ZERO; IF YES, ASK: How many times?)
_________ (Number of times (code 0 if "NO")
67c. Of those times (NUMBER) that you had sex with these people,
were you or they ever high on drugs or alcohol?
NO.......................................................................01
YES......................................................................02
229
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
67d. How many times?_____
68. Did you have anal sex with any of these other partners?
NO........................................................................01 (SKIP TO 69)
YES..................................................................... 02
68a. (IF YES) How many times?____________
68b. Of those (NUMBER) times, did you or your partner ever use a condom? (IF
NO, CODE ZERO; IF YES, ASK: How many times?)___________(Number of
times (code 0 if "NO").
68c. Of those (NUMBER) times that you had sex with these people, were you or
they ever high on drugs or alcohol?
NO....................................................................... 01
YES.....................................................................02
68d. How many times?_____
69. Still thinking about the past 90 days, I want to ask you some questions about
all of the clients [sex workers] that you had sex with during that period. First,
during the past 90 days did you ever ask any of these partners to use a condom?
NO........................................................................01 (SKIP TO 70)
YES..................................................................... 02
69a. (IF YES) How many times did you ask a partner to use a condom?
Number of times:_____
69b. Did any of your partners refuse to use a condom when you asked them?
NO........................................................................01 (SKIP TO 70)
YES..................................................................... 02
69c. (IF YES) How many times was your request to use a condom refused?
70. In the past 90 days, did you ever decide to have sex without a condom with
a client [sex worker] because:
a. you [sex worker] needed the money NO=1....................YES= 2
b. you didn't have a condom with you NO=1....................YES= 2
c. your client [you for males] didn't want to use a condom. NO/YES
70a. (IF YES) On how many occasions did you decide not to have sex?
Number of occasions:
71. Now I'd like to ask you about oral sex. By oral sex I mean when you put your
mouth on your partner's penis or vagina, or your partner puts his or her mouth or
230
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
tongue on your (vagina). During the past 90 days, did you have oral sex with any
of your (number) partners?
NO....................................................................... 01 (SKIP TO 72)
YES.....................................................................02
71a. All together, how many tim es?_______ (code 0 if "NO")
SECTION G :...........................SEXUAL ABUSE
72. Think about the time when you were growing up, before you were thirteen
years old. During that period— before you were thirteen— did you ever have
unwanted or uninvited sexual activity with anyone who was five or more years
older than you?
N O ...................................................................... 01
YES..................................................................... 02
73. Now think back to when you were 13 years old. Since you turned 13, did
anyone ever use verbal pressure or verbal threats to make you have unwanted
or uninvited sexual activity?
N O .......................................................................01
YES..................................................................... 02
74. Since you turned 13, has anyone used physical force or a weapon to force
you to have any sexual activity?
N O .......................................................................01
YES..................................................................... 02
75. Now during just the past 90 days— that is, since (date)— have you had
unwanted or uninvited sexual activity with someone because they threatened you
or physically forced you?
N O ...................................................................... 01
YES..................................................................... 02
SECTION H: HIV STATUS
I just want to remind you that some things you might tell me in the next questions
I will ask you, are reportable to the law. For example, if you tell me that you are
HIV positive and that you intend to have sex with a person and you give me
his/her name, and that person does not know you are HIV positive, I would have
to report it. Remember that you do not have to tell me anything that may make
you feel unsafe and you can stop this interview at any time.
76. Have you ever personally known anyone who has tested positive for the
virus that causes AIDS, or who has been diagnosed as having AIDS?
N O ...................................................................... 01
YES..................................................................... 02
231
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
76a. (IF YES) Was this person (or people): (CIRCLE ALL THAT
APPLY)
An acquaintance...............................................01
A friend.............................................................. 02
A very close friend........................................... 03
A family member...............................................04
A sex partner.................................................... 05
77. Have you ever been tested for the virus that causes AIDS?
NO........................................................................01 (SKIP TO 79)
YES.....................................................................02
77a. How many times have you been tested?_____________
77b. Have you been tested in the past 90 days?
N O ......................................................................01
YES.....................................................................02
78. Did you receive the results from your (most recent) test?
NO........................................................................ 01 (SKIP TO 79)
YES.....................................................................02
78a.Would you be willing to tell me the result of this test?
NO........................................................................ 01 (SKIP TO 80)
YES ................................................................ 02
78b. What was the result?
HIV NEGATIVE (doesn't have the virus) 01
HIV POSITIVE (has the virus).........................02
79. End tim e : -----AM/PM
232
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Appendix C
BI-DIRECTIONAL IVIODEL OF PRACTICE
SYSTEM
Cultural
Machismos
Sexual Silence
Health Beliefs
Structural
Poverty
Gender bias
Access
Racism
Migration
EMBODIMENT
Myths
Alienation
Fatalism
RISK
Drug use
Sex as escape
Sex as survival
Silent sexual encounters
PRAXIS
Reflection
Action
Practice
233
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
INFORMATION TO USERS
This manuscript has been reproduced from the microfilm master. UMI films
the text.directly from the original or copy submitted. Thus, some thesis and
dissertation copies are in typewriter face, while others may be from any type of
computer printer.
The quality o f this reproduction is dependent upon the quality o f the
copy submitted. Broken or indistinct print, colored or poor quality illustrations
and photographs, print bleedthrough, substandard margins, and improper
alignment can adversely affect reproduction.
In the unlikely event that the author did not send UMI a complete manuscript
and there are missing pages, these will be noted. Also, if unauthorized
copyright material had to be removed, a note will indicate the deletion.
Oversize materials (e.g., maps, drawings, charts) are reproduced by
sectioning the original, beginning at the upper left-hand comer and continuing
from left to right in equal sections with small overlaps.
Photographs included in the original manuscript have been reproduced
xerographically in this copy. Higher quality 6” x 9” black and white
photographic prints are available for any photographs or illustrations appearing
in this copy for an additional charge. Contact UMI directly to order.
Bell & Howell Information and Learning
300 North Zeeb Road, Ann Atbor, Ml 48106-1346 USA
800-521-0600
®
IMI
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
UMi Number: 9987589
Copyright 1999 by
Ayala, Armida
All rights reserved.
UMI
UMI Microform9987589
Copyright 2001 by Bell & Howell Information and Learning Company.
All rights reserved. This microform edition is protected against
unauthorized copying under Title 17, United States Code.
Bell & Howell Information and Learning Company
300 North Zeeb Road
P.O. Box 1346
Ann Arbor, Ml 48106-1346
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Alternate models of women's health care policy in the United States

PDF

This other darkness: exotic bodies and the gaze of romanticism

PDF

Uyghur neighborhoods and nationalisms in the former Sino-Soviet borderland: an historical ethnography of a stateless nation on the margins of modernity

PDF

Dual devotions: African American clergywomen and work-family dilemmas

PDF

Imaging alterity: discourse, pedagogy, and the reception of ethnographic film

PDF

Practicing policy and making myth: Applied anthropology and homeless service delivery in Glendale, California

PDF

Participation in informal labor markets: evidence from unauthorized Latina immigrants in Los Angeles County

PDF

Elevated inflammation in late life: predictors and outcomes

PDF

Identity configurations: re-inventing Samoan youth identities in urban California

PDF

Organizational development and coalition building among domestic violence agencies in California: conflict and compromise between grassroots groups and established institutions

PDF

The culture of beauty: agency and socialization within the sorority system

PDF

Novel phenylpolyene-bridged second-order nonlinear optical chromophores and new thermally stable polyurethanes for electro-optic applications

PDF

Iterative data detection: complexity reduction and applications

PDF

The role of the vasti in patellar kinematics and patellofemoral pain

PDF

It's only temporary?: The reproduction of gender and race inequalities in temporary clerical employment

PDF

Off the farm: rural Chinese women's experiences of labor mobility and modernity in post-Mao China (1984-2002)

PDF

The Lobas of Monthang: Loba ethnography and tourism as development

PDF

Semantic heterogeneity resolution in federated databases by meta-data implantation and stepwise evolution

PDF

Experimental and computational analysis of microsatellite repeat instability in mismatch-repair-deficient mice

PDF

Building a model of organization acculturation: an interpretive study of organizational culture and stories

Asset Metadata

Creator Ayala, Armida (author)

Core Title Mexican immigrant women, sex work, and health

Contributor Digitized by ProQuest (provenance)

School Graduate School

Degree Doctor of Philosophy

Degree Program Anthropology

Degree Conferral Date 1999-12

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag anthropology, cultural,health sciences,OAI-PMH Harvest,public health,sociology, ethnic and racial studies,women's studies

Language English

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c17-571357

Unique identifier UC11351848

Identifier 9987589.pdf (filename),usctheses-c17-571357 (legacy record id)

Legacy Identifier 9987589.pdf

Dmrecord 571357

Document Type Dissertation

Rights Ayala, Armida

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA