Introduction

Day laborers seek work in informal markets (typically outdoors, on street corners, in parking lots, in front of home-supply stores) or, less frequently, through community-based or private temporary-work staffing agencies (Valenzuela, 2003). The work is short-term—usually for a day or so only—and conveys no fringe benefits; jobs are frequently in construction, landscaping, or painting. In the Washington DC metropolitan area, over 90 % of day laborers are foreign-born Latino men (typically from Central America), and the majority has lived in the U.S. for less than 6 years (Valenzuela & Gonzalez, 2005).

Latinos constitute a group at high risk for HIV (CDC, 2010a). National data are not available for the day laborer population; however, local data from different regions indicate that Latino male day laborers have relatively high HIV rates. For example, a community testing program at two hiring sites in Los Angeles County found 4 % of Latino day laborers were HIV-positive (Galván & Martinez, 2006). In contrast, a sample that included six hiring sites in the same area found a much lower proportion–less than 1 % (Solorio & Galván, 2009). A review of research on a different but related group of workers in the U.S.—migrant laborers and seasonal farmworkers—suggested a disproportionately high prevalence of HIV, ranging from 3 to 5 % in Florida samples that included a large number of Latinos (Organista & Balls Organista, 1997).

One factor that might contribute to HIV infection among Latino day laborers is the hiring of sex workers, which has been found to be common in this population. In two recent samples, about a quarter of Latino day laborers in California reported sex with a sex worker in the previous 2 months (Organista & Kubo, 2005) and in the past year (Galván, Ortiz, Martínez, & Bing, 2009). In contrast, less than one percent of the general U.S. population reported sex with a sex worker in the previous year (Davis, Smith, & Marsden, 2005).

Using a conceptual framework entitled the Structural-Environmental (SE) model, proposed by Organista et al. (2012), the current study examined the question of whether sex with sex workers increases HIV risk among Latino day laborers. The approach posits that HIV risk occurs within the broader context of a person’s life. Factors potentially affecting risk include macro, structural conditions (e.g., poverty, laws concerning immigration), as well as the social and environmental contexts (e.g., separation from partners, prevalence of HIV in the partner pool, male patterns of social behavior). In addition, we view individual characteristics (e.g., level of acculturation, experiences of discrimination), as well as situational factors (e.g., partner characteristics or expectations, alcohol or drug use during the sexual encounter), as playing an important role in shaping behavior and risk. Because we believe that multi-level contextual factors can affect HIV risk, we examined several aspects of commercial sex work as it functions in the community of immigrant Latino day laborers in suburban Maryland, immediately adjacent to Washington, DC. We argue that to understand this group’s potential vulnerability to HIV in relation to sex work, it is necessary to investigate the ways in which sex work is structured, the factors that predict hiring sex workers, the behaviors performed, as well as the more restricted question of whether unprotected intercourse occurs.

There is currently disagreement in the literature concerning the role of sex workers in the HIV epidemic. A common perception is that sex workers serve as a vector in spreading HIV. For example, the United Nations Joint Programme on HIV/AIDS notes that female sex workers and their clients have higher HIV prevalence than the general population within a country (UNAIDS, 2002) and that sex workers represent a crucial focus for efforts to prevent the spread of HIV (UNAIDS, 2009). However, because structural conditions associated with sex work differ widely in different parts of the world, there is variation in the degree to which sex work contributes to the spread of HIV (Ward & Aral, 2006). In some places, sex workers enforce condom use with clients and thus prevent HIV transmission either to themselves or to their clients (Belza et al., 2004). Local laws and policies also have an impact, resulting in different levels of access to free condoms and engagement in safer sex training for sex workers, as found in a comparison of four Australian cities (Harcourt et al., 2010).

The risk related to sex with sex workers among Latino day laborers in the Washington DC area is not known. Among day laborers sampled in California, consistent condom use was not widespread with non-commercial partners, but was more common in sexual encounters with sex workers (Organista & Kubo, 2005). Galván et al. (2009) found that about three-quarters of Latino day laborers who had had sex with a sex worker in the previous year reported always using condoms; however, the remaining one-quarter either did not use condoms or did so inconsistently. In addition, a practice in which several men have sex with the same sex worker in succession has been reported (Organista, Balls Organista, García de Alba, Castillo Morán, & Ureta Carrillo, 1997), and in one study condoms were not used during this type of sexual encounter (Magaña, 1991).

Structural conditions clearly affect the extent of sex work commerce. Economic necessity is a major force propelling women or men into sex work (Harcourt & Donovan, 2005; Thukral, Ditmore, & Murphy, 2005). Similarly, lack of English proficiency severely limits job opportunities, which can result in engagement in sex work by either Latino men or women in the U.S. Among immigrant Latino day laborers, poverty and financial hardship can also restrict men’s chances of establishing or sustaining non-commercial partnerships and may threaten their ability to enact traditional masculine roles (Rhodes et al., 2009).

Structural and social conditions can also influence access to health care and prevention services, which in turn can affect the degree to which sex work involves HIV risk for either the sex workers or their day laborer clients. For example, concerns about immigration status or language barriers can prevent Latinos from seeking health care or participating in prevention programs, thus resulting in more undetected and untreated HIV and STIs, less knowledge about HIV and condoms, and therefore greater risk (Rhodes et al., 2009). Indeed, fear of deportation has been found to be a barrier to accessing resources not only among undocumented immigrants, but also among those with legal status (Arbana et al., 2010).

The high concentration of men within the community of Latino day laborers reflects a condition under which sex work commerce frequently flourishes, as has been demonstrated in many different settings with largely male labor networks (e.g., sailors: Trotter, 2009; miners: Tuan, 2010). Furthermore, the separation of immigrant day laborers from wives or girlfriends who remain in the country of origin has been associated with the hiring of sex workers (Galván et al., 2009; Lichtenstien, Hook, Grimley, St. Lawrence, & Bachman, 2008; Parrado, Flippen, & McQuiston, 2004; Viadro & Earp, 2000). In qualitative research, men have reported that they were seeking companionship, assuaging loneliness, and demonstrating masculinity through sexual encounters with sex workers and other women (Apostolopoulos et al., 2006; Hirsch, 2000; Muñoz-Laboy, Hirsch, & Quispe-Lazaro, 2009). Ethnographic research with sex workers in the U.S., Sweden, and the Netherlands has noted an important function of sex work is to supply companionship and emotional closeness (Bernstein, 2007). Similarly, participant-observation among strip and exotic club dancers revealed male clients’ motivation to attend the club often included conversation or “friendship” with the dancers (Egan, 2006; Frank, 2005).

Poverty can also increase Latino day laborers’ HIV risk by inducing these men to perform sex work with other men. Nearly three-quarters of Latino day laborers surveyed in California reported having heard of situations in which day laborers were offered money in exchange for sex (Ehrlich, Tholandi, & Martínez, 2006). In addition, five of six hiring sites in Los Angeles and the San Fernando Valley were identified on the Internet as locations at which men could solicit sex from male day laborers (Galván, Ortiz, Martínez, & Bing, 2008). Of migrant Latino day laborers surveyed at these sites, nearly two-fifths said that they had been approached. Of these, nearly one-tenth had engaged in sexual activities for pay, and a majority reported that they had not used condoms during anal intercourse in this context.

It is unclear what role, if any, difficulties associated with immigration and acculturation have in relation to HIV risk with sex workers. Latino day laborers, as well as Latina sex workers, face many challenges that can contribute to immigrant stress, including loneliness, poverty, discrimination, and loss of status (Lueck & Wilson, 2011; Rhodes et al., 2009; Suarez-Morales & Lopez, 2009). Adapting to life in a new environment is often difficult, and the process of acculturation is complex, occurring over multiple dimensions (e.g., language, identity, cultural competence) and involving incorporation of elements from the original and host culture (Schwartz, Unger, Zamboanga, & Szapocznik, 2010; Zea, Asner-Self, Birman, & Buki, 2003).

Individual characteristics, such as level of acculturation, might be associated with hiring or engaging in unprotected sex with sex workers. Although foreign-born Latinos tend to have worse economic situations, less access to health care, and lower education than U.S-born Latinos and non-Hispanic Whites, their health is better in a variety of areas (Acevedo-Garcia, Soobader & Berkman, 2005; Acevedo-Garcia, Bates, Osypuk, & McArdle, 2010; Alegría et al., 2007; Sanders, 2010; Singh & Siahpush, 2001)–a phenomenon known as the Latino Health Paradox (Dubowitz, Bates, & Acevedo-Garcia, 2010; Morales, Lara, Kington, Valdez, & Escarse, 2002). Recent research, however, has pointed out the inconsistency and complexity of this phenomenon (Fuller et al., 2009; Iribarren, Darbinian, Fireman, & Burchard, 2009), which is also the case relative to HIV vulnerability. For example, Latinos born in the U.S. have been found to be more likely to engage in early sexual activity or sexual risk behavior than immigrant Latinos (e.g., Adam, Husbands, Murray, & Marxwell, 2005; Jimenez, Potts, & Jimenez, 2002; Lee & Hahm, 2010), but lower acculturation in the U.S. has also been associated with greater likelihood of sexual risk (Faulkner & Mansfield, 2002; Ford & Norris, 1993), as well as less HIV testing and greater likelihood of positive serostatus (Kinsler et al., 2009; Lopez-Quintero, Shtarkshall, & Neumark, 2000).

Situational conditions, such as the use of alcohol or drugs, have also been associated with hiring of sex workers (Fernandez-Esquer, 2003; Galván et al., 2009). In some cases, this relationship is due to the context: for example, sex workers looking for clients sometimes do so in bars frequented by Latino day laborers (Ayala, Carrier, & Magaña, 1996). Binge drinking and other alcohol use in conjunction with sex have been reported in a sample of Latino day laborers; however, only a marginal relationship was found between alcohol use and sex with sex workers (Organista & Kubo, 2005). Moreover, research in a variety of populations has addressed the question of whether alcohol or drug use is related to increased sexual risk behavior (i.e., lack of condoms), but results have been inconsistent (O’Leary & Hatzenbuehler, 2009).

Current Study

Using qualitative and quantitative data, this study examined commercial sex in the Latino day laborer community in suburban Washington, DC. First, we explore the operational structure of sex work in the community of Latino immigrant day laborers. Next we examine the extent to which day laborers hire sex workers, as well as the structural, social, individual, and situational factors associated with doing so. We then describe the sexual behaviors performed with sex workers, investigate whether sex with sex workers increases vulnerability to HIV, and examine the practice of condom use within the structure of sex work. Finally, this study describes engagement in exchange sex by day laborers themselves.

Method

This research project included an initial qualitative phase. Because of limited funding and the exploratory nature of the qualitative phase, the number of interviews and focus groups conducted was small. Although the qualitative research was initially conceived with the purpose of identifying important themes and issues to be explored in the quantitative phase, the findings provided compelling data and information that were conceptually crucial to our understanding. Qualitative data sources were key informant interviews, focus groups, and in-depth interviews. Wording of questions used in the qualitative interviews, focus groups, as well as in the quantitative survey, was based on the previous experience of the authors in conducting HIV and sexual behavior research with Latino immigrant populations for over 10 years (e.g., Bianchi et al., 2007, 2010; Bianchi, Reisen, Zea, Poppen, & Echeverry, 2006; Reisen, Iracheta, Zea, Bianchi, & Poppen, 2010; Zea, Reisen, Poppen, & Bianchi, 2009).

Quantitative survey data were gathered through Audio Computer Assisted Self Interview (A-CASI). Inclusion criteria for the survey were being a Latino migrant day laborer; currently living in Montgomery or Prince George’s County, Maryland; being between the ages of 18 and 40 years; having been born in Latin America; and having migrated to the United States as an adult (18 years or older). Similar criteria were used for focus groups and in-depth interviews, without the age restriction. In addition, participants in the quantitative survey were all registered as day laborers with CASA de Maryland, a non-profit organization serving the day laborer population. Inclusion criteria for the women included being Latina, female, and a sex worker providing services to Latino day laborers. Data collection was carried out between the fall of 2009 and winter of 2010, in partnership with CASA de Maryland.

Participants and Procedure: Qualitative Phase

Key Informant Interviews

Individuals knowledgeable about Latino day laborers in the Washington, DC metropolitan area were identified as potential key informants. Ten key informant interviews were conducted with community leaders, labor center managers, health promoters/educators associated with CASA de Maryland, and physicians. The interviews focused on the social and structural conditions potentially related to sexual risk among Latino day laborers. Key informant interviews lasted from one to 2 h and were conducted in English or Spanish, depending on the preference of the person being interviewed. These interviews were performed at the beginning of the study and informed the development of the quantitative survey and the qualitative guides for the focus groups and in-depth interviews.

Focus groups

A total of 11 men from suburban Maryland participated in two separate focus groups (N = 5 and N = 6). As suggested by Krueger (2006), focus group sizes were kept small to increase the level of comfort among participants and to encourage greater participation from all members of the group on a relatively personal and sensitive topic. The composition of groups was also relatively homogenous (Krueger, 1994): all participants were Latino immigrant day laborers and the majority were single, born in Central America, and had low educational levels. Focus group guides were used to center the conversation around immigration, social, and sexual experiences of Latino day laborers. All focus groups were conducted in Spanish and lasted approximately two and a half hours. The men were reimbursed $50 for their participation.

In-Depth Interviews

Ten semi-structured in-depth interviews were conducted with male Latino day laborers, and four interviews were conducted with Latina female sex workers who provided their services to Latino day laborers. Interviews were conducted in Spanish by a male researcher with the men and by a female researcher with the women. Staff from CASA de Maryland and other Latino day laborers referred potential participants to the study. The women were referred by other sex workers or by Latino staff from agencies working with sex workers. Interview guides for the day laborers focused mainly on immigration, discrimination experiences, drinking behaviors, social isolation, sexual behaviors and risk factors, as well as HIV testing, attitudes, awareness, and knowledge. Topics covered in the interviews with the female sex workers included living and working conditions, condom use, and perceptions of and sexual experiences with Latino day laborers. All interviews lasted approximately 90 min, and participants received $50 in reimbursement for their time.

Data Analysis

All focus groups and interviews were digitally recorded, and data were transcribed in Spanish for analysis using NVivo 8. Interviews were coded in the original language by a team of three bilingual Latino researchers, one of whom was a native speaker of Spanish. Two researchers coded the focus groups and first few interviews simultaneously until criteria for coding were established. A third researcher served as a reviewer and compared the coding in order to identity discrepancies. Differences in coding were resolved through discussion and consensus among all three coders. The approach for coding data was constructivist and iterative in nature.

A pre-established set of codes based upon the focus group and in-depth interview guides and the conceptual framework were initially used, but ideas were revised and definitions expanded based upon the new understandings gained through the qualitative analysis process. The content areas covered by the coding scheme were broad and included the following subcategories: life issues and conditions (e.g., family, migration, financial conditions, health); discrimination and exploitation issues (e.g., anti-immigrant, employer, racial); sexual relations (e.g., sex in exchange, sex work, relationship with sexual partners); HIV and STIs (e.g., HIV testing, stigma and knowledge, condom use); social life (e.g., drugs and alcohol, friends, community, violence); and mental health (e.g., isolation, sadness). Not all codes were applied to both the day laborers and sex workers, and for this analysis we used the codes that were most relevant to the focus of this paper, which were sexual relations, social life, HIV/STIs, and mental health. Open coding and memos were used to allow and account for revisions of code definitions and additional new codes within subcategories (Richards, 2005). Memos were mainly used to record observations about the data that could be helpful during interpretation of findings and to indicate decisions regarding coding definitions and the creation of new codes. Every time new codes were created, all interviews and focus groups were recoded for that particular code in order to achieve accuracy and consistency throughout the coding process.

Qualitative data for this study below are presented with quotations from participants labeled by type of source and participant number (e.g., DL01 is day laborer number 1; FSW01 is female sex worker number 1, and FG1-01 is participant number 1 in focus group 1). Table 1 shows demographic characteristics of participants in the in-depth interviews and focus groups, including country of birth, marital status, education level, age, and years in the US.

Table 1 Characteristics of qualitative sample
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Participants, Procedure, and Measures: Quantitative Phase

A-CASI Survey

Feedback on the preliminary version of the quantitative survey was obtained from two additional focus groups, one with professionals working with the day laborer community (N = 6) and one with day laborers (N = 5). Five individual Latino day laborers also took the preliminary version of the survey and provided feedback. Based on the information obtained, revisions were made in the survey. All measures were translated from English to Spanish by native speakers, and back-translated into English to ensure accuracy of the language. Quantitative surveys covered several broad topic areas, including immigration experiences, acculturation, discrimination, depression, sexual behavior, HIV attitudes and testing, access to medical care, and demographics. Measures used in this paper included questions about immigrant stress, discrimination for being Latino, binge drinking, two indicators of acculturation (i.e., time in the US and English proficiency), sex with sex workers, and individual characteristics reflecting separation from spouse and poverty.

Immigrant Stress

Stress related to being an immigrant was measured with an adaptation of the immigration subscale of the Hispanic Stress Inventory (Cervantes, Padilla, & Snyder, 1991). Four items from the subscale were used in this study and consisted of questions about: feeling guilty for leaving family, perceived loss of respect in the U.S., fear of being deported, and being treated badly for not speaking English well. In addition, a question about perceived fear of growing anti-immigrant sentiments was included. The Likert scale response format ranged from 1 = Strongly Disagree to 5 = Strongly Agree. Internal consistency reliability with this sample was .67.

Discrimination

Experiences of discrimination associated with being a Latino immigrant were measured with a 4-item version of a scale developed by Díaz, Ayala, Bein, Henne, and Marin (2001). The original 7-item scale was designed to assess psychological mistreatment, verbal harassment, and physical assault based on racial/ethnic background. In this study, participants were asked to indicate in a 4-point response format ranging from 1 = Never to 4 = Many times the extent to which they had been verbally abused, punched, bothered by the police, and made feel uncomfortable in public places because they were Latino immigrants. Internal consistency was .71.

Binge drinking

Binge drinking was assessed by first asking participants if they had consumed any alcoholic beverage in the last 30 days. If the person answered in the affirmative, then the follow-up question was, “In the last 30 days, how many times did you have 5 or more alcoholic beverages in a single occasion?” The response format ranged from 0 = Not at all to 4 = At least once a day. For analytic purposes, this variable was dichotomized to reflect any binge drinking vs. no binge drinking in the previous 30 days.

Acculturation

We asked questions about time in the U.S. and English proficiency, which are both important aspects of the acculturation process. Participants were first asked: “How many years has it been since you first came to the U.S.?” To assess linguistic acculturation, we asked how well the participant spoke English, with response options ranging from 0 = Not at all to 4 = Very well.

Sex work

Several questions covered the topic of sex work and were based in part on information obtained in the qualitative phase. Participants were allowed to select more than one response for each question. Questions included the men’s perceptions concerning how sex workers approach potential clients (e.g., business cards, friends) and locations where sex with sex workers occurs (e.g., homes, bars). Those who indicated that they “had ever had sex with a sex worker (or prostitute who receives money in exchange for having sex)” were asked additional questions concerning motivations (e.g., lack of companionship, relief from sexual urges) and sexual behaviors (e.g. vaginal sex, anal sex), including the number of times they had sex with a sex worker in the last 6 months and condom use.

Exchange Sex

Participants were asked to indicate if they had ever engaged in exchange sex where they either received or gave something for sex (e.g., food, drugs, place to stay). In addition, we asked the men if they had ever heard of or had been approached by employers offering to pay money for sex. Moreover, we inquired about ever having “felt forced” by an employer to have sex. Response formats were either “yes” or “no” for each question.

Demographic Characteristics

Demographic questions covered age, income, education, and country of birth. In addition, participants were asked whether they had enough money to meet their basic needs (e.g., housing, food, clothing). Partner status was ascertained by asking if participants currently had a partner or spouse in the US. Lastly, participants were also asked whether they ever had been tested for HIV and, if so, the results of their tests.

Table 2 provides descriptive information on participants in the quantitative survey. The quantitative sample was mostly composed of Central-American immigrants who were single, poor, and with low levels of education. The mean number of years in the U.S. was about 6 years, and half had been in this country five years or fewer. Most were not very proficient in the English language.

Table 2 Characteristics of the quantitative sample (N = 174)
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Procedure for Survey

The A-CASI survey was administered to 174 male Latino day laborers at four different labor centers managed by CASA de Maryland in Montgomery and Prince George’s Counties. Because there are many more day laborers than work opportunities on any given day, CASA de Maryland uses a rotating system to distribute jobs. The research assistant approached those men who did not have job assignments. He described the study and determined if the man was interested and eligible. Approximately 96 % of the men whom he approached and were determined to be eligible agreed to participate in the study.

Participants took the survey in a private room, either one or two at a time, with separate computers placed in a manner to ensure privacy. The research assistant went over the consent form and, upon obtaining consent, administered a brief training session introducing the use of A-CASI. Day laborers with low literacy were able to participate by using the audio presentation of questions and response options. In addition, if they preferred, the research assistant would take them to a private area or schedule an individual session in which he could read questions to the participants. The average time taken to complete the survey was 25 min. Men were reimbursed $20 for their participation.

Results

Operational Structure of Sex Work

Sex work commerce serving Latino day laborers in the Washington DC area is situated within the immigrant community. In this study, the sex workers whom the men reported hiring were themselves Latina immigrants. As described by this sample, business was conducted in Spanish and was located in predominantly Latino neighborhoods.

The quantitative survey provided information about the structure of sex work within the community of Latino day laborers as perceived by the clients. One issue concerned the ways in which day laborers find sex workers (see Table 3). As can be seen in the table, common means were through friends, business cards (tarjetas), and pimps (cuidanderos). Much less frequent mechanisms were via the Internet or being approached by sex workers who worked primarily on the street. In the qualitative interviews and focus groups that preceded the survey, the men noted that the tarjetas often offered other types of services (e.g., car repair, sale of roses or perfume) as a way to mask their real purpose and thus to avoid problems with law enforcement. A participant described the use of tarjetas in this way:

Table 3 Experiences of Latino day laborers with sex workers
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I went to send some money to my country, a remittance. As I was leaving, I was suddenly approached by a person. He said to me, “Come here. Hey, don’t you want to have some fun?” And he gave me a business card “[Blank] Mechanic” And, well, I had already heard about that, but it had never happened to me. So they give you a number that says it is for a mechanic or for anything else, say a plumber, but in reality it is so that you can call a prostitute. [DL04]

Qualitative data also revealed that the men perceived picking up women on the street as posing potential risks, such as problems with the police and exposure to sexually transmitted infections (STIs).

Locations where sex with sex workers occurred are also shown in Table 3. As seen in the findings from the quantitative survey, the day laborers reported that the most common location was in an apartment or house. The term “delivery,” which was first identified in the qualitative research and then used in the quantitative survey, describes a common practice in which a sex worker is called to come to a residence to serve individual clients or a group of men. Day laborers would also go to apartments or houses which functioned as brothels (casa de citas). Qualitative data with day laborers and female sex workers revealed that the casa de citas were under the management of cuidanderos, and a small number of female sex workers were typically available. The female sex workers serving the Latino day laborers in this area are mostly Latinas, usually immigrants from Central America. Whether they work independently or under a cuidandero, most are called treinteras, because they charge 30 (treinta) dollars for 15 min.

A quarter of the participants in the quantitative survey who had ever had sex with a sex worker reported that they had participated as part of a group of men in a “delivery.” Qualitative research elucidated the details. Although a group of men would be present, the sex worker would have sex with them one at a time. A participant described this practice in the following way:

Sometimes, maybe we are drinking a beer, and say I am craving for a girl. “Let’s call her.”…OK, so I am going to call her. There will be two, three, or four of us. So we call her and she asks, “How many people are there? Are you the only one who wants some [sex]? There are not many people?” There are four, two, three. So, she comes and knows that she will profit; she will earn her money. So she goes, that’s how it is. [DL05]

Participants described these sexual occasions as typically involving a combination of socializing and drinking, and at times, tobacco and drug use. A focus group participant drew an interesting analogy between the delivery and a tamal, which is a typical dish in Latin America:

A tamal that does not have all the ingredients is not good, right? The tamal, if it does not have salt and all of that,…so if there is not a woman, the situation isn’t good. If there aren’t drugs, it isn’t good. So I have seen groups, because I live where they use those things a lot, first they start with tobacco, then comes the 12-pack of beer, then comes the most important, the biggest thing which is cocaine, then once that comes the result is that the woman comes. That is the final step, because they have all of that in their minds. The final thing that comes is the woman, to enjoy her better they say. [FG1-01]

Although the in-depth interviews with female sex workers were originally designed to provide information relevant to Latino day laborers, they revealed additional details concerning the business arrangements in sex work transactions. Some women work independently, while others work under the supervision and control of cuidanderos who would sometimes drive a group of sex workers to different locations to serve clients.

There are differing advantages and disadvantages for the sex workers in the various types of arrangements. Those who work on their own are able to keep the entire fee and have some choice about their work activities. For example, female sex workers reported that they sometimes refused to perform a “delivery” if the men were drunk or high on drugs, because they feared that the men would become abusive or the police would get involved. However, the women who work independently also run some additional risks. For example, gangs may force them to pay in order to operate in an area under gang control. In addition, these women are sometimes victimized by their clients, who do not pay for their services or who force them to perform sex acts against their will (e.g., to have anal sex, to continue having sex after the allotted time.)

In contrast, the women who work under a cuidandero have less control over their working conditions and schedule. One sex worker described the situation in this way:

[The pimp] already had a house and would not let them [the women] go anywhere–only when it was time to go to work. And he would set some goals for them. He would ask how many [clients] one could do, 15 to 20 in the morning or in the afternoon. [FSW 02]

Cuidanderos also strictly enforce the number of men served and the amount of time spent with clients by the women. As one day laborer explained: [The cuidandero] travels with them, keeps the time, and if [the sex worker] is not there [out of the bedroom after 15 min], then he is calling to rush her.” [DL07] The women rarely encountered the problem of clients who did not pay, because the cuidanderos collected the fees before any sex occurred; however, the cuidanderos kept a large portion of the fees (typically half). In addition, in the casa de citas the women were sometimes required to pay for condoms, alcohol, and other supplies.

Structural and Social Factors Associated with Sex with Sex Workers

Extent of Hiring Sex Workers

Of the 174 men surveyed, 74 (43 %) reported having had sex with a sex worker at some time in their lives, and 52 men (30 %) reported doing so in the previous 6 months. In this latter group, the mean number of times that the men hired a sex worker was 6.1. The distribution was skewed, however, and three-fifths of the men had sex with a sex worker three times or fewer, whereas some individual participants reported more than 30 or 40 visits within the last 6 months.

Fifty-seven percent of the day laborers reported never having had sex with a sex worker. In focus groups and interviews, some talked about reasons why they chose not to have sex with sex workers. One concern was related to health: the men were afraid that they would contract HIV or another sexually transmitted infection. In addition, other reasons given were not having sufficient money, seeing sex with sex workers as immoral, and not wanting to be distracted from goals for being in this country. As a participant in the second focus group explained:

There are people who waste money on alcohol and women. They don’t think about how much it costs them to earn the money…For example, in my case, I don’t even know what a “treintera” is. I don’t know what it is like to pay a woman $25, $30 to have sex. I, as the man that I am, prefer a million times to masturbate. I save thirty dollars, plus in this economy in which I don’t have work, one has to think. One has to know how to manage one’s money because it costs us to earn it. Plus there are a lot of infections, HIV, AIDS. [FG2-04]

Factors Associated with Hiring Sex Workers

Logistic regression analysis was performed to test a model predicting the dichotomous outcome of having had sex with a sex worker in the previous 6 months. Predictors included having a partner in the U.S., immigrant stress, experiences of discrimination, having sufficient money for basic needs, binge drinking in the last month, time in the U.S., and English proficiency. Based on the literature (Galván et al., 2009; Lichtenstien et al., 2008; Parrado et al., 2004; Viadro & Earp, 2000), we hypothesized that not having a partner or wife in the U.S. would be associated with a greater likelihood of hiring a sex worker. We included several variables related to the context of the men’s lives (immigrant stress, experiences of discrimination, sufficient money for basic needs, binge drinking), but did not make directional hypotheses due to a lack of information or inconsistent findings in the literature. We also explored the impact of two indicators of acculturation: time in the U.S. and English proficiency.

As can be seen in Table 4, in keeping with our hypothesis, having a partner in the U.S. was strongly negatively associated with sex with sex workers. Men without a wife or partner in the U.S. were over five times more likely to have had sex with a sex worker in the previous 6 months than those with a wife or partner here. In addition, we found that those men who reported binge drinking were three times as likely to have had sex with a sex worker. Similarly, sex with a sex worker was nearly twice as likely among men with greater immigrant stress. Discrimination experiences, sufficient money for basic necessities, years in the U.S., and ability to speak English were not significantly related to the probability of sex with a sex worker.

Table 4 Logistic regression predicting sex with a sex worker in the previous 6 months (N = 174)
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Table 3 shows the percent of the men who endorsed specific reasons for having sex with a sex worker. The subsample that completed these questions included only those participants who had had sex with a sex worker in the previous 6 months (n = 52). About two-thirds said that they were motivated to have sex with a sex worker because of lack of companionship. More than half gave the lack of commitment and sexual relief associated with sex with a sex worker as their reasons.

Qualitative interviews provided additional details about motivations to have sex with a sex worker. For example, one participant noted the lack of availability of women: “It is difficult to find [female partners]…and the only option left is for one to find someone and pay her. And that is what I had to do”. [DL02] Another man described the motivation as arising from sexual needs:

What is it that they feel? Let’s say if they use a treintera, they feel good. It’s to say…they can’t hold out for so many years, so there are types of men that, in their mind, they want to have a woman. So those are the types of men that cannot handle it, so through a friend or someone, since one is desperate to bust a nut, they go and ask, “Have you heard of a place that rents women?” [DL04]

Another participant noted the emotional reasons for hiring sex workers: Depending on the sadness and loneliness, one calls a girl. [DL09] Because the qualitative data indicated that some men established ongoing, personal relationships with specific sex workers, we also asked in the quantitative survey whether the men regularly sought out a specific sex worker. This pattern was not reported widely in the quantitative survey: only 10 of the men who had ever had sex with a sex worker (13.5 %) had done so. Of these, three reported that they called that sex worker just to talk, and one man said that he had had sex without a condom with that particular woman. Interviews with sex workers suggested that women who worked independently (without a cuidandero) were more likely to have a regular client base. Two of the sex workers described ongoing personal relationships with some of the men they served. In one case, the woman had known the clients for a long time (e.g., 5 years), felt comfortable in the men’s homes, listened to their problems, and offered them advice:

They take care of me a lot, and I take care of them, and I always give them advice too. The advice that I get at CASA de Maryland, I give to my clients [about safe sexual practices]…They tell me the problems they have, and I at times, in what I know, I advise them. [FSW 01]

Another motivation to seek sex with sex workers may stem from the limited recreational activities available to many day laborers. The focus on finding and doing work, as well as the need to save money, can lead to boredom and feelings of stress. As one man said when explaining the motivation to hire sex workers: “It is to kill time, understand? It is to get out of the stress, because it is all about work, work, and then people go crazy”. [FG1-05]

Sexual behaviors and risk

Table 2 shows that of those men who had been tested for HIV (65 %), 93 % reported being HIV-negative, and 7 % either did not remember or never got their results. These numbers suggest a possible absence of HIV in this sample. The question of whether sex with sex workers poses risk for HIV is directly related to the sexual activities and the use of condoms. Table 3 indicates the sexual behaviors that Latino day laborers reported performing with sex workers. By far the most common behavior was vaginal intercourse, which was reported by over three-quarters of the 52 men who had had sex with a sex worker in the previous 6 months. Oral sex was less common, and anal intercourse was reported by less than 10 %.

Of the 74 participants in the quantitative survey who had ever had sex with a sex worker, ten men (13.5 %) reported having had unprotected sex with a sex worker at some time. Of these, two participants said that they had paid the sex worker more in order to forego condom use. In addition, nine of these ten men reported that they had used condoms at their most recent sexual encounter with a sex worker; one man did not remember. All the other men reported always using a condom during sex with a sex worker. Thus, it is evident that there is very little unprotected sex occurring among the Latino day laborers and the female sex workers whom they hire. The limited number of men who had ever had sex with a sex worker without a condom prevented us from exploring characteristics associated with this behavior.

Qualitative findings provided additional details concerning sexual encounters between day laborers and sex workers. Female sex workers described the basic service as including only vaginal intercourse with a condom and a single penetration, and all reported that they did not kiss their clients. The treinteras typically undressed only partially during vaginal intercourse—keeping on their clothes above the waist. One day laborer said:

Everything is real simple, everything is real simple. No hugs, no kisses, nothing like that. It is fifteen minutes and nothing more than fifteen minutes that one is there and has to get his business done, right? So you are there, if you didn’t finish, well that is your own problem. [DL05]

Other activities, such as oral or anal sex and touching breasts, required an additional charge. A focus group participant described a negotiation during a sexual encounter in this manner:

“Can I kiss your breasts?”

“No, you cannot,” they say. “Well, if you want, give me another $10, and you can kiss my breasts… so it will last a little longer.”

“Oh, look, can I have anal sex with you?”

“Oh you want to? Give me another $20.” And it works like that, that is the reality of things. [FG2-02]

The sex workers or their cuidanderos typically provided condoms and required condom use for vaginal and sometimes oral sex. In addition, some cuidanderos performed regular HIV testing on the women. Moreover, some sex workers and day laborers reported that there were cuidanderos who monitored their sex workers by not only providing condoms, but also counting the number used at the end of a “shift.” Therefore, it is evident that most sex workers and cuidanderos enforced condom use with the clients. Day laborers expressed the belief that sex workers who approached clients on the street were the exception, possibly because of desperation stemming from drug dependence.

Despite a general practice of requiring condom use, qualitative data revealed that in rare instances indoor sex workers would agree to have unprotected sex for more money. It is interesting to note that for women who worked under a cuidandero, such arrangements were likely to be made without the involvement or knowledge of the cuidandero, who would typically require condom use. The direct negotiation between the sex worker and the client in the bedroom enabled the sex worker to keep the additional money charged for sex without a condom.

Male Exchange Sex

Day laborers who themselves engage in sex work or exchange sex have another source of HIV risk, and particularly those with male clients. Therefore, we asked participants in the quantitative survey about situations in which sex was performed in order to obtain something such as food or a place to stay. Although exchange sex was mentioned several times in the key informant interviews, only 10 percent of the day laborers surveyed (N = 17) reported having given someone something in exchange for sex, whereas six percent reported having received something in exchange for sex. The extent to which condoms were used during these sexual encounters was not assessed in our study. In focus groups, a couple of day laborers reported that some men they knew had had sex with another man in order to pay for food and rent:

There are people who pay other people to have sex with them. That has happened here, we cannot deny it….Hmm, I imagine that it is also because of the economic situation. I think that the person who likes women, no matter how ugly the woman is, they are going to prefer to have sex with a woman than a man. So I can only think that they do it out of necessity…the pressure of being able to pay rent. I assume food too. This has become the case a lot. [FG1-04]

Quantitative data revealed that the day laborers themselves are sometimes solicited to have sex in exchange for money. Nearly one-fifth of the participants said that they had heard of day laborers being approached at work and offered money for sex, and five percent reported that an employer had asked them to have sex for money. In addition, two individuals said that in their work as day laborers, they had at some time “felt forced” to have sex with an employer. Although we did not specify in the quantitative survey the gender of the employers who were seeking sex with sex workers, based on key informant and in-depth interviews, it appears that they are men.

Discussion

The findings of this study indicate that sex with sex workers poses little risk of HIV transmission for Latino day laborers in suburban Maryland. The sex workers or their cuidanderos typically enforced condom use, and condom use with sex workers was nearly universally reported in this sample of day laborers. These findings are in contrast to results of other research indicating a substantial proportion of day laborers in California did not use condoms consistently (Galván et al., 2009). The widespread use of condoms may reflect the effectiveness of prevention and educational efforts in HIV/AIDS by local health programs in the Washington, DC metropolitan area. For example, CASA de Maryland and other non-profit organizations have developed and implemented aggressive programs to educate the Latino population about safe sexual practices and HIV testing. One sex worker reported having attended these programs, and another noted that she taught her clients the safe sex practices that she had learned.

Thus, rather than increasing the Latino day laborers’ HIV risk, the sex workers were supporting prevention efforts. This finding is consistent with other research indicating that in some contexts, sex workers act to prevent HIV transmission by requiring condom use (Belza et al., 2004; Ward & Aral, 2006). The results challenge the argument that sex workers are vectors spreading the epidemic, and rather, suggest the opposite.

The majority of the men in this study had been tested for HIV, and no one reported positive serostatus, although several men said that they had not received or did not remember their results. Even if those men were actually positive, the findings suggest that HIV is not the threat to Latino day laborers that it had seemed to be in other settings (Galván & Martinez, 2006; Organista & Balls Organista, 1997). The absence of HIV in the small Maryland sample, but the comparable proportion of men reporting sex with sex workers to that reported in California samples (Galván et al., 2009; Organista & Kubo 2005), could be a result of greater condom use among some groups of Latino day laborers and sex workers, including those in the Washington, DC area. It is also possible, however, that the discrepancy stems from differences in HIV prevalence and community viral load in different areas, which have been shown to be related to the probability of transmission and, hence, to HIV incidence (Das et al., 2010; Montaner et al., 2010).

Another possible explanation for the lower HIV prevalence reported by our sample of day laborers in comparison to some California samples could stem from differences in the extent to which the day laborers engage in sex work with other men as clients. Poverty is an influential condition in the lives of many Latino day laborers. Even though the practice was not widespread, having sex in exchange for food or a place to stay was reported. Like many female sex workers, financial need may drive Latino day laborers into having sex with men for money. The opportunity to earn money or meet survival needs through sex work with men may be more apparent at some hiring sites in California, which the Internet identifies as locations for soliciting sex from day laborers (Galván et al., 2008). Whereas three-quarters of men in a California sample had heard of day laborers being approached to have sex with other men for money (Erlich et al., 2006), less than a fifth of the Maryland sample in this study had. Moreover, nearly two-fifths of day laborers surveyed in Los Angeles had themselves been approached by men looking for sex (Galván et al., 2008), in contrast to 5 % in this study. Because men who have sex with men (MSM) represent a group with high HIV prevalence (CDC, 2010b), having sex with MSM and engaging in anal intercourse (Chan, 2005) could greatly increase risk of contracting HIV. Unfortunately, we did not ask whether condoms were used during exchange sex with another male to be able to assess the level of risk in the sample.

There are other differences in the social and structural conditions for the day laborer population in California, where the majority are Mexican (Erlich et al., 2006), and in Maryland, where the majority are Central American. Factors such as cultural background, rural or urban origins, drug use behavior, and migratory patterns could all contribute to discrepancies in HIV risk and prevalence. In addition, the characteristics of the sex workers whom the men hire could vary. There is a high prevalence of HIV among sex workers in Mexican border cities (e.g., 6 % in Tijuana: Strathdee & Magis-Rodriguez, 2008), and the California day laborers are more likely to have spent time there.

Social and Structural Factors and the Hiring of Sex Workers

The structural condition of being separated from families and intimate partners is faced by many immigrants. Similar to findings from previous research (Apostolopoulos et al., 2006; Galván et al., 2009; Hirsch, 2000; Muñoz-Laboy et al., 2009; Parrado et al., 2004; Viadro & Earp, 2000), this study found a significant relationship between not having a partner in the U.S. and having sex with sex workers. Lack of companionship was the most common reason reported for hiring a sex worker. Moreover, day laborers and sex workers described the importance of the men’s loneliness as a motivation. The findings are consistent with the argument made by Bernstein (2007) that sex workers supply clients with not only sexual acts, but also intimacy. In the current study, we also heard reports from independent sex workers that they fulfilled intimacy needs of some of their regular clients and provided advice and social support. Like the indoor sex workers described by Bernstein (2007), these women tended to be more middle-class than street-based workers and to have more control over their work lives than either the street-based workers or those functioning under a cuidandero. As was the case with regular clients of strip club dancers (Frank, 2005), conversation was an important aspect of the companionship that these women supplied.

The social and structural aspects of the day laborers’ lives can lead to immigrant stress, which was associated with having sex with sex workers. Results suggested that feelings of stress, which could stem from fears about deportation or rising anti-immigrant sentiments, strains related to lack of English proficiency or lower status and respect, and guilt about leaving home, can result in feelings of tension and distress. The day laborers were motivated to have sex with sex workers for a variety of reasons, including to forget their problems, to have fun, and to relieve sexual urges. Thus, like the customers in strip clubs (Frank, 2005), a major motivation for the men was to have a way to relax.

Often Latino day laborers focus on working and saving money and have constrained life circumstances. Socializing with other men and getting a “delivery” are among the few ways that the men relax and engage in recreation. Moreover, consistent with Egan’s (2006) research on exotic dance clubs, such situations enable men to enact some traditional masculine behaviors, such as drinking and displaying sexual interest with women.

Situational Factors: Binge Drinking and Sex with Sex Workers

Organista & Kubo (2005) reported only a marginal association between binge drinking and sex with sex workers; however, the present study found a strong link between the behaviors of binge drinking and hiring sex workers. Furthermore, qualitative data revealed that drinking was often associated with a pattern of socializing among Latino day laborers which also included sex with a sex worker. The phenomenon of the “delivery” was common, and thus, the social structure itself supported the combination of alcohol and sex with sex workers. Although in this study the use of alcohol was not associated with unprotected sex, a breach in safe sexual practices during a “delivery” or in a brothel could expose sequential clients to increased risk of STIs, including HIV.

Limitations and Future Implications

The current study had small sample for both the qualitative and quantitative portions. In addition, the fact that all the men surveyed were registered as day laborers with CASA de Maryland may have introduced a systematic bias in the results. Many of these men have been exposed to the educational and prevention programs available at CASA de Maryland, as have some of the sex workers whom they hire. The majority of day laborers who seek work on the street corners probably have not received the same type of information and may be at a higher risk. Indeed, one key informant who had been a health educator in the Latino community said that he perceived most day laborers on the street corners as less educated about condom use. Future studies could examine subgroup differences among day laborers on a variety of risk behaviors. In addition, future research could explore the role of acculturation to a greater extent, taking into account the complex and multi-dimensional nature of this construct.

The inclusion of interviews with Latina sex workers who offered their services to day laborers provided a valuable additional perspective in this study; however, the small number of sex workers interviewed and their demographic homogeneity posed a limitation to the study. Some structural and social conditions affecting day laborers are similar for the sex workers, who face analogous situations as immigrants in a foreign culture and language, separated from family and friends, with little economic opportunity or security. Indeed, there are some parallel job challenges for street-based sex workers and day laborers. Both groups wait on street corners to be picked up by potential employers, and neither group is protected from dangerous working conditions or abuse. Future research could explore systemic interventions addressing the needs of both groups.

Although we found that condom use was normative among sex workers in suburban Maryland, the financial incentives for unprotected sex could be compelling. Sex workers can earn more money for sex without a condom, and agreements made privately in the bedroom enable the women to keep additional fees without the cuidandero taking a proportion. In addition, some sex workers engage in other practices that could increase their vulnerability to infectious disease, such as using cocaine or Vicks Vaporub in their vaginas in order to serve multiple clients in succession. There is a need for health programs culturally and linguistically tailored to Latina sex workers in the Washington metropolitan area, as currently there are none.

Conclusion

Latinos in the U.S. are a group with disproportionately high prevalence and incidence of HIV. One possible mode of HIV transmission among Latino day laborers is the practice of having sex with sex workers, which is quite common in this population. Findings of this study indicate that sex with sex workers was not an important source of HIV transmission among day laborers in this region. Condom use during sex with sex workers was commonly reported by the day laborers, and was typically required by the female sex workers, despite financial incentives to make exceptions. Structural and social conditions were seen as influencing the men’s hiring of sex workers. Separation from partners, stress related to immigration, and binge drinking were all related to greater likelihood of having sex with a sex worker. Further research and intervention programs, as well as policy changes, are necessary to address the needs of this hard-to-reach and understudied population of Latino immigrants, including the day laborers and the female sex workers whom they hire.