Gay Bathhouse HIV Prevention: the Use of Staff Monitoring of Patron Sexual Behavior
Many HIV prevention interventions have been launched in gay bathhouses and sex clubs since the onset of the AIDS epidemic, such as condom distribution and HIV testing. Perhaps none of these are as intrusive to the venue's environment as what is called “monitoring,” which involves staff, during every shift, repeatedly walking throughout the public areas of a bathhouse to check on patrons’ sexual behavior. Yet, monitoring has received little evaluation. Between 2002 and 2004, we conducted qualitative interviews with venue managers, staff, and patrons in New York City, Los Angeles, and the San Francisco Bay Area. An analysis found that monitoring was influenced by the kinds of space available for sex, suggesting three approaches to monitoring: (1) monitoring all sex in clubs that only had public areas where men had sex, (2) monitoring some sex in clubs with private rooms for sex, and (3) no monitoring of sex, regardless of the kinds of space for sex.
KeywordsHIV preventionMonitoringBathhousesSex clubsGay menMSM
The responsibility of managers to monitor the sexual behavior of patrons in gay bathhouses has a circuitous history. In the period between the onset of gay liberation (traditionally marked at about 1969) but before onset of the AIDS epidemic among gay men (1981), gay bathhouses and sex clubs began to multiply dramatically (Woods et al. 2003b). Unlike earlier periods when sexual behavior needed to be discreet, gay bathhouses emerged as significant institutions supporting the burgeoning gay culture (Berube 2003). These gay spaces provided a place of exploration for the gay male sexuality and sociality that was safely removed from the repressive gaze of heteronormative society (Halperin 1995; Rubin 2004; Tattleman 1997; Winkler 2006). Thus, in the period just prior to AIDS, bathhouses were reputable for their absolute lack of monitoring. AIDS dramatically changed these venues in form and function.
In response to the AIDS epidemic of the early 1980s, sexual behavior in gay bathhouses drew significant attention from health officials, politicians, and journalists (Bayer 1989; Berube 2003; Disman 2003). Prior to the epidemic, bathhouses had long been considered much safer places, in terms of risks of assault or robbery, than the many other types of public venues where men met for sex (Berube 2003; Weinberg and Williams 1975). However, given the contours of the early HIV epidemic in most urban areas (Turner et al. 1989), bathhouses became associated with risk for HIV. Thus, bathhouses drew the particular interest of public health officials intent to reduce HIV transmission by intervening in these settings (Bayer 1989; Shilts 1987). Some bathhouses and sex clubs were closed permanently by health officials, but in those that remained open, rules prohibiting certain sexual practices were enforced by staff as well as by health department personnel. Monitoring of sexual behavior in clubs developed as a means to enforce these rules and comply with new regulations to avoid being shut down by the local officials. The primary focus of this paper is an examination and evaluation of this monitoring of specific types of sexual behavior (depending on local regulations) in gay bathhouses as a strategy to prevent HIV transmission.
Bathhouses and Sex Clubs
Although there are nominal differences between “bathhouses” (have a sauna, steam room, or pool; patrons wear towels) and “sex clubs” (have spaces for sex; patrons wear street clothes), both provide a space that is safe for men to interact socially and sexually. Bathhouses and sex clubs have many attributes in common that make them similar to each other and different from other types of commercial sex environments (CSEs), such as bookstores and movie houses (Woods and Binson 2003). Hereafter, the term “club” is used inclusively to capture any kind of bathhouse or sex club (but exclusively of other CSEs, such as book stores and movie houses).
All clubs require that patrons check-in at entry, pay a fee, and, usually, check out to leave. When entering and exiting, men pass through a secured door. These measures have a psychological function of separating the outside world from the club environment. Throughout the club, patrons are in various stages of undress, pornography may be playing on televisions, and men may be engaged in a range of sexual activities in full view (Brown 1979; Delph 1978; Rumaker 1979; Styles 1979; Tattleman 1997, 1999; Weinberg and Williams 1975). As a result, the sexual and social interactions tend to be more overtly sexual and contact more explicitly sexual or solely homosexual in clubs than in other CSEs. These shared characteristics make clubs similar in terms of considering possibilities for HIV prevention. The privacy from outside intrusion means, for instance, that prevention messages can be sexually explicit and targeted appropriately in ways that are not possible in other public locations.
Nevertheless, there also are differences across clubs that influence HIV prevention efforts. While some clubs offer private rooms with doors, others have only public spaces that offer a mere hint of privacy (i.e., no doors to prevent others from seeing the activity). Clubs vary from one another according to the kinds of sexual behavior that are permitted in the public spaces: some clubs do not allow any overtly sexual behavior; other clubs do not restrict sexual behavior in public at all. Clubs also differ in terms of their size (Woods et al. 2010), primarily in terms of the building’s footprint and number of floors, which in turn affects the size of the club in terms of the number of staff required to run the club and the maximum number of patrons it can accommodate at one time. Clubs with private rooms tend to have a larger physical floor plan than clubs that do not have private rooms.
Another way clubs vary is in their ability to offer amenities typically associated with health clubs, i.e., pools, Jacuzzis, showers, saunas. Clubs also may provide any of a range of social spaces, such as lounges to read, talk, watch television, or eat (US clubs do not offer alcohol, whereas clubs in some countries do); game rooms; and outdoor areas. Public sex spaces offered in some clubs include dark rooms, orgy rooms, mazes, and cubicles. In many of these types of spaces, there are glory holes and sometimes slings or other bondage paraphernalia. The availability of these amenities often depends on the size of the club, as well as local regulations. For instance, clubs in jurisdictions that prohibit any sex in public areas are likely to offer private rooms but have no public areas where sex is permitted.
Health and Prevention
Even before the AIDS epidemic, health officials recognized that clubs provided an excellent opportunity to reach men at high risk for sexually transmitted infections, and screening was made available at some clubs (Binson et al. 2005; Darrow et al. 1981; Merino et al. 1979; Ritchey and Leff 1975). At the outset of the AIDS epidemic, clubs were an instrument through which health educators could reach and inform men of the new disease (Berube 2003; Bolton et al. 1992; Woods and Binson 2003). There is some evidence to suggest that many men learned about AIDS from information they picked up at the clubs (Richwald et al. 1988). This kind of information was widely available in San Francisco clubs at least as early as 1984 (Helquist and Osmon 1984) and, along with condoms and lubrication, continued to be available in US clubs (Binson et al. 2010; Woods et al. 2001).
As it became clear that the AIDS epidemic was entrenched among gay men, it became more and more difficult for public health officials simply to use the bathhouse as a means of providing important information to men at risk (Bayer 1989; Berube 2003; Disman 2003; Shilts 1987). There was a political expectation that more be done officially, and efforts were made starting in 1984 to close the bathhouses, sex clubs, and other commercial sex venues (i.e., adult bookstores and movie houses). San Francisco was the first city to take action, and soon other jurisdictions followed, with New York, Los Angeles, and Atlanta all having closed at least some of their clubs by 1986 (Woods and Binson 2003). However, this was primarily a US response. The only country other than the USA to close its bathhouses in response to the AIDS epidemic was Sweden in 1985 (Henriksson 1988), reversing that ban in 2004 (Sved 2009, personal communication). Attempts to close the clubs in US cities were ultimately unsuccessful because either the local jurisdictions were only able to close some of the clubs (Bayer 1989), or courts found a middle ground allowing the businesses to operate as long as they followed certain guidelines (Carrel and Klosinski 1996; Sved 2009, personal communication).
US health jurisdictions took divergent policy approaches to HIV prevention in clubs. In some places, monitoring of sexual behavior is specifically required as part of the regulations so that the layout of the venue is designed to meet the requirement to monitor patron sexual behavior. In other cases, monitoring of sexual behavior is a necessary function to enforce the regulations, but monitoring itself is not mandated by the policy (e.g., sex is prohibited in public areas of the club and so managers have to monitor to enforce the policy). Also, the varieties of regulations include differences in which sexual behaviors must or need to be monitored to meet the requirements of the regulations, some prohibit any sexual contact that involves inserting the penis inside another person, and others restrict only behavior demonstrated to have an association with HIV transmission. As a consequence of nearly 25 years of monitoring patron sexual behavior, this intervention is thought of as a prevention program particularly suited to promoting safe sex among patrons (Kegebein et al. 1992; Wohlfeiler and Ellen 2007). Nevertheless, the policy has met with skepticism; some argue that monitoring adults engaged in sex is counterproductive; it “takes responsibility away from the individual and thrust it on some outside source … away from what is safe and unsafe, to what one can get away with” (p. 113) (Gendin 1996).
Despite these conflicting perspectives on monitoring, there has been no evaluation of monitoring sexual behavior as a prevention intervention. If monitoring is to work as an intervention, club management, staff, and even patrons to some extent must agree on its purpose and collaboratively work to implement it. However, given that monitoring may undermine patrons’ personal responsibility, assessment of stakeholder opinions of “monitoring as prevention” is critical and long overdue. Between 2002 and 2004, we conducted an extensive qualitative study of prevention activities in the clubs in New York City, Los Angeles County, and three San Francisco Bay Area jurisdictions (Binson and Woods 2003). These data provide a unique opportunity to assess monitoring in five jurisdictions representing different approaches to HIV prevention in clubs. We use the available data to describe and evaluate monitoring as required (or not) by local policy to reduce HIV transmission and promote safer sex behavior.
Monitoring policy by health jurisdiction
Health policy regarding monitoring in clubs
No specific monitoring policies
Nevertheless, two clubs had rules prohibiting sex in public areas, necessitating that staff monitor public spaces to enforce club rules
No specific monitoring policies
However, strictly enforced codes prohibited penetrative sex, which meant that club staff monitored the club’s public areas to ensure that no sex occurred. Clubs with private spaces monitored to ensure that doors were closed when occupied by more than one person
Had a specific monitoring policy
Private rooms were prohibited in clubs and club managers were to have staff ensure that condoms were used during anal sex
No specific monitoring policies
No specific monitoring policies
Managers were approached by letter and a follow-up phone call with a request to participate in the interview. Those who agreed to participate were asked to allow us to recruit staff using flyers passed out to staff. Both managers and staff were included by virtue of their role and willingness to participate in an interview; there were no further eligibility criteria except having been working in their position for at least 6 months. We did not ask for personal information about age, race/ethnicity, health status, or risk behavior, although it was obvious that they were mostly white and managers were on average were older than the patrons. Patrons were recruited with posted fliers and active engagement by recruiters at the participating bathhouses. When they called in to schedule an interview, they were screened for age, race/ethnicity, and HIV status to assure diversity across these factors, as well as for how recently they visited the bathhouse and their sexual behavior during the visit to assure that they would have information useful to the overall purpose of the study. About half of the patrons participating in the study were white, followed by African-American/Black, Hispanic/Latino, Asian/Pacific Islander, and men of mixed heritage. Their ages ranged from early 20s to late 60s. More than a third were HIV-positive or of unknown HIV status.
We conducted in-depth qualitative interviews with club managers (some of whom were also owners), club staff, and patrons on a number of topics related to the role of clubs in HIV prevention. Participants were asked to describe the components of the club’s HIV prevention program; there was no specific question that directly raised the issue of monitoring. The study design enabled us to triangulate the distinct perspectives of managers, staff, and patrons to provide a rich description of the impact of club monitoring policies on stakeholders’ roles and relationships.
The authors collaboratively and iteratively analyzed the data using ATLAS.ti software (ATLAS.ti. 2002). The first phase of analysis consisted of developing a common set of concepts based on patterns observed in the data. Initially, the team analyzed the same data to compare, line by line, how each of us delimited and coded the data segments. All new codes proposed by team members were vetted, renamed, and defined during analysis meetings. Out of this process emerged a common approach to selecting the boundaries of data segments and to reach agreement on the definitions of our growing list of codes. Once we found that our coding of the data produced no new classes of codes, just refinements of existing codes, we divided up the remainder of the data among us, coded them independently, but continued to discuss our progress and to review segments we had found particularly interesting or difficult to code. While independently coding the text, we recorded our annotations using memos. Each of the authors then reviewed all the data from one club in order to triangulate with the different perspectives obtained through manager, staff, and patron interviews. We then analyzed all the data from each of the jurisdictions so as to identify broader patterns and differences across the jurisdictions. For this analysis, we reviewed all quotes linked to the code for “monitoring.”
Number of clubs and participants by city
San Francisco Bay Area
The physical environment of clubs can be described as one of three types: Either the club is comprised of only open areas where men have sex (i.e., there are no private rooms), or men have sex only in private places (i.e., none of the public areas are intended to be used for sex); or there are both public and private areas for sex. We identified three approaches to monitoring that were, in part, distinguished by the kind of sex spaces available: (1) monitoring all sex in clubs that only had public areas where men had sex, (2) monitoring some sex in clubs with private rooms for sex, and (3) no monitoring of sex, regardless of the kinds of space for sex. These three monitoring approaches are generally associated with the three geographic areas; however, they were not exact matches. Within the San Francisco Bay Area, for instance, there were two jurisdictions that used one approach and a third that used a different approach. Similarly in Los Angeles, there were no local policies, but some of the clubs chose to enforce a monitoring policy, while others did not.
Monitoring in Clubs with All Sex in Public Areas
There were clubs with only public areas for sex (i.e., no private rooms) in all three metropolitan areas, although monitoring was used only in San Francisco and New York City clubs. In San Francisco, only unprotected anal sex was prohibited, while in New York any sex that involved inserting a penis in any orifice was prohibited. In both cities, staff monitored to ensure that sex on the premises conformed to the local rules.
The 1985 public health guidelines for San Francisco clubs stipulated the opening up of private spaces to facilitate monitoring of sexual risk behavior (Disman 2003). Over time San Francisco clubs eliminated private rooms altogether: “There are no locking doors anywhere in the club and there are no doors that don't have some way of seeing in through them” (M:4BA). Managers found various ways to balance the patron’s desire for some privacy with the need to monitor. One manager said that there were “a lot of littler spaces that have swinging doors that do not lock where you can see through but give some semblance of privacy…enough that you can have a good time but not feel like your mom's watching” (M:4BA). Other managers described how patron expectations of privacy were altered by monitoring. One manager claims that although the club’s open layout tends to attract a more “exhibitionist” clientele, he admits that the loss of privacy was “everybody's biggest complaint” (M:2BA). He dismisses this complaint by pointing out that if patrons were really so concerned about privacy, “you can meet somebody and take them home for privacy.” Club managers described monitoring as a means to protect patrons from themselves: “I think people will tend to not be as safe if they're behind closed doors … when they [are] not supervised they fall back into their old ways” (M:2BA). Another manager indicated his conviction that monitoring was central to operating a club and that even if private rooms were available, “I think most people would still probably be safe, but there would be no way then to know what was going on and no way to monitor that” (M:4BA).
When I take care of a problem, I try to do it in such a way that it doesn't shame or humiliate the person I'm talking to, particularly if it has to do around safer sex issues… I think people understand that I'm trying … to fulfill the responsibilities that I have to the owners of the club and that they have to the Department of Public Health, and maybe [to the] larger society as a whole, but at the same time, be an advocate for gay men.
Because staffing is limited, the success of enforcement of local sex rules relies on self-monitoring by patrons. As one manager reported, “[T]he other thing that makes our rules enforceable more than even our staff walking through is that we have the community's eyes on them while they’re in our club … they're in front of the community and the community here is expecting good, clean, healthy, safe sex” (M:6BA). As one patron confirmed, he went to the club just to chat with staff and to help “monitor the floors and stuff, make sure everyone’s playing safe…” (P3:3BA). One manager attributed the collaborative approach to monitoring to the fact that gay men “don’t want to lose play spaces” (M:3NY).
Club policies toward violators varied. One manger said that “the first time that they are caught fucking without a condom they're 86'd [ejected] for the night; the second time for six months, and we've never had a third time, but the third time would be forever” (M:4BA). Another manager wrote off violations as a onetime thing stating, “the problem you always encounter is somebody gets caught up in the heat of passion,” but, “my philosophy always was, ‘You screwed up tonight, leave; you come back tomorrow, we’re still friends’” (M:3NY). Several managers emphasized that they eject both sexual partners along with spectators, “We had to kick out five guys about a month ago because there were two guys who were barebacking [having anal sex without condoms] and three guys who were sort of trying to block the staff's view so we kicked out the whole lot” (M:4BA).
[U]ltimately it’s up to the individual … I don’t think that it’s wise to go around and slap people’s wrists with sex monitors ’cause it’s just going to piss people off and … people are going to rebel … when they’re told that they can’t do something that they want to do. It’s between two consenting adults. (P4:3NY)
San Francisco is the only city in the study that specifically mandated monitoring of patrons’ sexual behavior. At the time of the study, the clubs operating in San Francisco had opened for business after the main elements of the regulations were clearly established, so club owners designed the spaces without doors and with adequate lighting to comply with the monitoring policy. Managers may also have embraced monitoring because they had a role in creating the guidelines that were developed by the local health department. Though the managers spoke as if they valued monitoring, they still sometimes referred to it in derogatory terms (e.g., “guards,” “not feel like your mom’s watching”) and recognized that some patrons want privacy.
The comments of staff, however, suggested that the influence of managers’ convictions had limits. While some staff members might enjoy the opportunity to walk the club for monitor duty, their experience interacting with patrons in their role as monitors was primarily described as demoralizing. Staff acknowledged that they could not be everywhere and did not attempt to catch all proscribed behavior. Also, staff worked under the burden of monitoring for condom use when patrons were engaged in anal sex. As participants admitted, it is not easy to determine whether someone is using a condom during anal sex even in open areas. As part of a 1996 study of sexual behavior in some of these same sex clubs, study staff counted anal intercourse encounters during study observation periods and were unable to determine if a condom was used in more than three-quarters of the encounters (Woods et al. 1996). There also were striking references to the punitive effect of monitoring (e.g., being “a policeman”—an ironic comment in light of the fact that clubs originated as a way to escape the gaze of the state/police that made homosexuality a crime).
While staff often found monitoring dispiriting because it contributed to a transgressive, catch-me-if-you-can dynamic between staff and patrons, patrons accepted monitoring as the price for their ability to have sex clubs available to use. Staff and managers often relied on regular patrons’ willingness to report unsafe patron activity to staff.
Monitoring in Clubs with Private Rooms and No Sex in Public
Clubs that have private rooms sometimes have regulations about not having sex in public areas of the club, and the facility provides none of the common public areas where men might expect to be able to have sex (such as an orgy room or a dark room). Two Los Angeles clubs with private rooms used monitoring of public areas to move sex into private rooms, although no reason was given for their club policy. In New York, stakeholders were clear that the state policy prohibiting any penetrative sexual behavior on the premises was responsible for the decision to monitor in these clubs, making sure that all sexual activity was pushed out of the public areas into private rooms, behind closed doors.
The primary means of communicating the requirements of the New York law was to post rules and then to enforce them by having staff monitor the public spaces by roaming through the club. A manager said that “there are signs that tell them there’s no public sex. But, you know, they … pay no attention to them, so we still have a monitor, going around and make sure that there’s no public sex” (M:1NY). Another manager said that “we have monitors throughout the place … we check the hot room and steam room to make sure that they do not cover [the light] with a towel for it to be dark in there” (M:5NY). Many managers readily acknowledged that the monitoring was in response to the threat of closure by the city: “Because we have people from the health department unannounced that come here to make sure that you're doing what you're supposed to do” (M:5NY). Patrons found breaking the rules were asked to stop or take it into a private room. As one manager put it: “whatever happens behind closed doors, we have no jurisdiction on that…” (M:5NY).
Enforcement centered primarily on efforts to keep private room doors closed. Men typically cruise the hallways while other patrons in their private rooms leave their door open to indicate their availability. A patron explained this phenomena can occur even after a man is invited into another man’s room, “people like other people to watch and they will try while they’re having sex to leave the door open or to invite a stranger in … a few guys that have done that and the guard has come by and say, ‘Listen, you know, if you don’t keep the door closed, I'm going to ask you to leave’” (P2:2NY). Despite claims by one manager (M:5NY) that “we’re open 24 h. and we have people checking on each shift,” patrons reported that enforcement was often lax. A patron from one club said that the prohibition of sex in public was “neither enforced nor followed … we engage in that constantly and there's no supervision or effort to control that … it’s a small staff” (P2:1NY). Another patron from that same club reported that he had not seen monitoring done at the club (P3:1NY). Another patron suggested that monitors lacked motivation: “everybody wants to watch. And then if the attendant goes by and says, ‘Fellows, you can’t do that’ so—but that’s as far as they get. I don’t think their heart is in it” (P1:4NY). A patron from yet another club indicated that the monitoring began “only recently that—within maybe the last year—they’ve hired an actual guard that’s walking around and making sure that people are not having public sex” (P2:2NY).
Sometimes patrons request a room in “Siberia,” i.e., someplace off the beaten track where they “will not be observed by the staff” (P1:4NY). Another patron described different levels of monitoring within the club: “The downstairs is … monitored but not as closely and there’s not as many people.” Then again, he complained that it was “almost too well policed” and a “little too much supervision” (P1:2NY).
There are free condoms everywhere. There’s safe sex information everywhere. We can’t force people to have safe sex anywhere be it at home or here. We can do what we can to promote it, but we can’t enforce it (S:3LA).
Patrons also had trouble seeing the value of monitoring in these clubs. One patron (P5:3LA) reported that “You just really can’t control people, because people want to do what they really want to do, and they want to have fun.”
In clubs with private rooms that used monitoring to keep sex out of the public areas of the club, there was a notable difference between clubs that engaged in monitoring to shield the club from scrutiny by outside regulators (i.e., in New York) and those who employed monitoring to enforce club rules (i.e., in Los Angeles). Managers and staff using monitoring to satisfy regulators found it a painful and unwelcomed activity. Patrons did not take monitoring seriously, although managers and patrons recognized that the risk of closure for violation of New York state law was real (in fact, at least one club was closed at the start of data collection). By comparison, managers in clubs using monitoring for enforcing their own rules embraced it with enthusiasm. Also, implementation of monitoring by staff was spotty and patrons were unimpressed by the monitoring efforts in these clubs.
There were clubs that had no staff monitoring of patron sexual behavior regardless of the physical space, i.e., whether there were private rooms or only public areas where men had sex. Thus, any observation of patron sexual behavior by staff occurred only in the course of regular maintenance and operation of the club. The majority of clubs in the study had no monitoring, and we found clubs using this approach in all three metropolitan areas (even where some kind of monitoring was required by local policy or needed to enforce local policy). In one club, the manager (M:1LA) mentioned that the point of the layout of the club was to enhance the sexual excitement by allowing men to see men having sex, adding that while the staff of his club had some responsibility to circulate to check on things and some regulars helped to keep an eye on “commotion” that can arise, there was no monitoring of patron sexual behavior by staff. According to one staff member, “for the most part, as employees, we try to stay out of [a public area for sex] … to provide privacy for the customers” (S:5BA).
One manager discussed why the club did not monitor public sex even though his club was in a jurisdiction that mandates monitoring. He believed that men come to his club because they want privacy, “they want to get away from everybody - from the prying eyes of people. And I guess they just don't want people to watch them fuck” (M:7BA). A staff participant from this club mentioned that “on occasion—I have gone up to some people that look like they might be doing something I didn’t want them to do and just tap them on the shoulder and remind them that we don't do that here. But … [management] never told me to go out there every half hour or every hour or something. It's just whenever I have time and I think of it” (S:7BA). A patron participant from this club said that “there's only one staff member [at the club at any given time] and they're not out there patrolling the whole club so … [you do] not have to worry about anybody watching you or monitoring you.” As a comparison, he mentioned his experiences with another San Francisco club that monitors, which he’d visited recently, “It just ruins the moment 'cause you're afraid you're going to get kicked out or something” (P3:7BA).
[M]onitoring sets a number of tones that go in absolute opposition to [the club’s] philosophy … that individuals should be given the information necessary to make choices for themselves as to what's best for them … If people begin to feel that they're being controlled they're going to resent it and they're going to resist it, even if it's to their own detriment.
Similarly, a manager at another club said that his club “is a safe sex zone” and that “people sort of understand what that means … we make sure that there's condoms available for everybody at all times and I think along with peer pressure it encourages certain types of behavior” (M:5BA).
Patrons, however, were of two minds about the absence of monitoring of public sex. One patron captured the ambivalence when he expressed his belief that the clubs should “86 [keep] people out, who… are basically ruining the situation for the rest of us … it’s just really difficult to control people’s behaviors in there” (P5:3LA). While patrons reported that they believed that the patrons themselves were responsible for their own behavior, several were concerned by the fact that they witnessed what they perceived to be high-risk behavior in the clubs. One patron (P1:1LA) who thought there should be monitoring, as he had seen in other cities, stressed that the lack of monitoring implied that the club does not care about the patrons, while another patron (P2:5BA) repeated the notion that the club ultimately cannot control what patrons do while at the club.
Not surprisingly, managers and staff were in sync concerning their roles and responsibilities in clubs that did not monitor patron sexual behavior. Staff circulated through the public areas of the club as part of their routine of checking the club for cleanliness and order but did not have a responsibility to monitor patrons’ sexual activity. It was noteworthy that managers who did not have staff monitoring patron sexual behavior raised the issue of monitoring and had very strong feelings about it. In some cases, this might be a result of the proximity of a club to other clubs that did monitor or to some unmentioned event that made managers comment (i.e., other California jurisdictions). Although managers and staff seemed comfortable with not monitoring patron sexual behavior in the club, patrons appeared ambivalent. But even among this group, men struggled with the reality that grown men must take responsibility to protect themselves and their partners, even as they found it frustrating when they witnessed what they considered irresponsible behavior by other patrons.
The analysis of the data on monitoring patron sexual behavior in clubs revealed that the various ways that clubs apply the practice can be organized in three distinct types (i.e., monitoring all sex, monitoring some sex, monitoring no sex). The kind of environment provided for sex (i.e., whether there are only public areas for sex or whether private rooms are available and sex is not permitted in public areas) played an important role in the kind of monitoring that was possible.
The results indicate that approaches to monitoring differed among clubs, sometimes even in the same jurisdictions, and that the kinds of spaces available for sex determined to some extent the kind of monitoring that would take place, if monitoring was used. They also show that there was widespread ambivalence on the question of club responsibility for patron behavior. Having no monitoring approach was the least intrusive and least dispiriting for managers and staff, although no monitoring was seen as problematic for those patrons left with the perception that the club does not care about them. Our findings suggest that one important function of monitoring is to convey the manager’s concern about HIV and patron safety, even if monitoring is simply a matter of “security theater” like the enhanced pat downs at airport security checkpoints. Of course, an alternative to monitoring might be promoting other very visible prevention activities that communicate that the management cares about the patrons’ health and safety, such as on-site HIV testing programs (Binson et al. 2005; Daskalakis, et al. 2009; Woods et al. 2008), as well as other programs that have not been evaluated: extensive condom distribution, posted signs and educational materials, special events such as safer-sex demonstrations, outreach programs, and individual counseling services (Woods et al. 2001, 2010).
Of significant concern was the insight that the monitoring can have the effect of encouraging patrons to act out in resistance to the policy. One of the unintended consequences of monitoring is that the risk of punishment and the challenge of having unprotected sex without detection by staff only adds to the excitement of the sexual experience (Gendin 1996). Comments by patron stakeholders suggest that overzealous monitoring appeared to incite transgressive behavior.
The present analysis was limited to the impact of these policies on the stakeholders most directly affected by the intervention, namely club managers, staff, and patrons. Although the data do not begin to address the efficacy of any of the monitoring approaches, the fact that patrons reported that they themselves participated in or observed sexual risk behavior in all the clubs indicates that none of the monitoring approaches were having the desired impact of eliminating unprotected anal intercourse (UAI) in these venues. Available data from exit surveys with probability samples drawn from clubs that do not use monitoring suggest that the rate of sexual risk in these clubs is low (Bingham et al. 2008; Binson et al. 2010; Reidy et al. 2009; Woods et al. 2007), but no comparable data are available for clubs using either of the other monitoring approaches. Population data of men who have sex with men from these three urban areas, as well as Chicago, showed that there were no overall differences in numbers of partners, number of one-night stands, or number of occasions of sexual risk in public settings (Woods et al. 2003a). The results did show that men in San Francisco reported lower rates of high risk sex in a bathhouse. However, the authors pointed out that there were problems with this particular measure, raising questions as to whether the monitoring in San Francisco clubs was in fact having an effect on risk behavior (Wohlfeiler and Ellen 2007; Woods et al. 2011). Further information is needed to determine whether the two kinds of club environments that use monitoring have similar rates of risk behavior and if they actually reduce risk behavior or simply attract a different, less risk-prone population.
The data were collected between 2002 and 2004, about 5 to 10 years after the New York City and San Francisco policies were fully developed and implemented. Although almost as much time has elapsed since data collection, the policies in both cities are still in place. Los Angeles has since completely revamped its HIV policies for bathhouses, but the new policy does not require that staff monitor patron sexual behavior on the premises. Several of the businesses that participated in our study have since closed, but in general, the number of bathhouses and sex clubs across the country has remained unchanged over the past 20 years (Woods et al. 2010). With the growth of the internet, a number of alternative venues have started or grown since 2002, including sex parties and online cruise sites (Benotsch et al. 2002; Clatts et al. 2005; Friedman et al. 2008; Landovitz et al. 2012; Liau et al. 2006; Solomon et al 2011). Care should be taken in translating the experiences described in this study, for as the data show, monitoring depends on the kinds of space where sex takes place and bathhouses and sex clubs are unique among sex venues (Woods and Binson 2003).
Data from the study indicate that monitoring of patron sexual behavior conditions the relationships and roles of managers and staff with their patrons, in both positive and negative ways. While the data cannot reveal which monitoring approach is best to implement, they do suggest that implementation of monitoring does present problems for many managers, most staff, and some patrons. Of concern is that a consistent comment from a number of patron informants from clubs across the three approaches suggests that some men rebel against monitoring, i.e., either they have witnessed others engaging in the proscribed behavior, they themselves engage in it, or they seek out places that are not monitored. It would seem logical that rebellion against public health messages of safer sex in a population highly impacted by HIV should be avoided. Given that UAI in venues that do not monitor has been shown to be rare, interventions that engage club patrons, rather than monitoring their behaviors, might be a more promising path for HIV prevention interventions in these settings.
This study was funded by the National Institute of Mental Health: R01 MH61162. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIMH. The authors want to express our great appreciation to Kim Koester and Jeff McConnell of UCSF, whose manuscript reviews greatly improved this product; to our project director, Paul Cotten, without whom this project could not have been launched; and to all the club managers, staff, and patrons who agreed to collaborate with us on this study.