Sexual Behaviors in an Urban Bathhouse 15 Years into the HIV Epidemic
Bathhouses and sex clubs now operate in many cities in the United States and other countries. In Oregon, bathhouses and sex clubs are legal; sex between consenting adults is permitted if it does not occur in a public place. In the past ten years, up to five privately owned bathhouses or sex clubs have operated in Oregon. In 1996, members of the Cascade AIDS Project, the management at one Portland-based bathhouse with which CAP had built a working relationship, and state and local public health departments developed and administered a survey for bathhouse patrons. Researchers characterized the population of men visiting the bathhouse, described their sexual behaviors, and determined the proportion and characteristics of men who engage in sexual behavior at highest risk for transmitting HIV. The bathhouse surveyed is a private club requiring yearly membership. Each week, the bathhouse receives more than 600 visits, most being made by repeat visitors. Over 80 days, all men entering the bathhouse were asked to complete a one-page, anonymous questionnaire. Data collection ended when 1,000 surveys were obtained. During all hours of operation, bathhouse clerks handed out the questionnaire. As an incentive to participate, each member was offered a modest entry fee discount for completing the survey. The patron's membership card was punched on return of the survey, and only patrons with unpunched cards were eligible to participate. Questionnaires assessed demographics, self-reported HIV-status, sexual behavior and condom use in the preceding 30 days. Researchers defined high-risk behavior as anal sex (either insertive or receptive) without a condom at a bathhouse in the previous 30 days.
Although an exact response rate could not be determined, bathhouse employees estimated that 80 percent to 90 percent of patrons completed the study. Respondents came from more than 33 states and eight foreign countries; 658 (68 percent) were from Oregon. Most respondents were white (84 percent), similar to Oregon's racial distribution; the remainder were African-American (4.6 percent), Latino (3.7 percent), Native American (3.3 percent) or Asian (3.1 percent). The median age of respondents was 38 (range 19-81 years). Eight hundred thirty-nine (86 percent) respondents had completed at least some college, and 294 (30 percent) had obtained an advanced degree. Six hundred eight (61 percent) respondents reported visiting a bathhouse at least monthly; 37 (3.7 percent) indicated that the current visit was their first time at this venue. Seven hundred fourteen (71 percent) reported that they were gay, 248 (25 percent) bisexual, and 13 (1.3 percent) heterosexual; 25 (2.6 percent) did not answer the question. Of 1,000 respondents, 829 (83 percent) reported having anal or oral sex at a bathhouse in the previous 30 days. Of that group, the mean number of male partners in the previous 30 days in the bathhouse was four (range 1-50) and in other venues was three (range 1-65); 715 (86 percent) engaged in oral sex; 420 (51 percent) in anal sex; and 89 (11 percent) in high-risk (unprotected anal) sex.
Of the 89 men who engaged in at least one episode of high-risk sex, 21 (24 percent) stated that they were bisexual, and one (1 percent) stated he was heterosexual; 14 (16 percent) of these 89 respondents reported having had sex with a woman in the previous 30 days. The mean number of male sex partners at a bathhouse in the previous 30 days was seven (median, 4; range, 1-30). Sixty-three (75 percent) respondents went to places other than bathhouses for anonymous sex. Sixteen (18 percent) respondents reported they were HIV-positive. In multivariate analysis, characteristics associated with men reporting high-risk sex compared with men reporting other sexual activities at the bathhouse were being HIV-positive (OR, 2.2; 95 percent CI); being unaware of HIV status; ³5 sexual partners in previous 30 days (OR, 3.2; 95 percent CI); having anonymous sex at other sites (OR, 2.1; 95 percent CI). Although most bathhouse patrons engaged in lower risk activities, a small but significant subset of patrons reported sexual behaviors at greatest risk for HIV transmission. In addition, those reporting unprotected anal sex were more likely to report HIV infection and to have multiple sexual partners. Still, nearly two-thirds of all respondents stated that they had anonymous sex at venues other than a bathhouse. Also, 45 percent of men who had high-risk sex also reported having anal sex at other venues. Researchers concluded that well into the HIV epidemic, bathhouses remain venues for ongoing spread of HIV and opportunities for intervention.