To the Editor:
The mathematic model provided by Faissol and colleagues1 is a welcome addition to the data available to guide public health policy concerning gay bathhouses and sex clubs. Data from our work in this area of research provide evidence to support their model, which suggested that keeping bathhouses open is likely to decrease the HIV attack rate (ie, annual number of new cases divided by susceptible people) in the adult population of men who have sex with men (MSM). A recent survey of MSM exiting a bathhouse found that 11.1% of respondents reported engaging in unprotected anal intercourse (UAI) during their just-completed bathhouse visit.2 Other studies of risk behavior at bathhouses found similar results,3,4 as do investigations by government officials (eg, see the article by Disman5). These findings are also in line with our previous analysis of Urban Men's Health Study data (UMHS 1997, the same data set used by Faissol et al1), which showed that among adult urban MSM who reported going to public settings to meet men for sex, the proportion reporting UAI in a public setting was 4.3% for men who go only to cruising areas (eg, parks and adult bookstores) but not to bathhouses or sex clubs, 10.1% for men who go only to bathhouses and sex clubs but not to cruising areas, and 21.6% for men who go to both types of places. For comparison, the rates of UAI with any nonprimary partner (ie, in a public setting or not) for those 3 groups were 20.0%, 33.9%, and 50.4%, respectively.6 Thus, even though a large proportion of men who engage in UAI in a public setting go to bathhouses, the practice of UAI inside the bathhouse seems to be more the exception than the norm it can seem to be to the casual observer (eg, see Farley7) and far less prevalent than UAI with a casual partner in general. More specifically, one must keep in mind that engaging in UAI in a bathhouse or other public setting during a given period does not equate to engaging in UAI every time one had sex in those venues.
Based on their model results, the authors also discuss the possibility that a policy to close bathhouses could decrease the HIV attack rate if the closure resulted in no change in condom use and a dramatic decrease in the number of sex acts. Some readers may assume, based on “common sense,” that such consequences likely would result from closing the bathhouses. Nevertheless, the evidence from available data suggests the opposite (ie, if bathhouses are closed, condom use would decline and the number of sex acts would remain constant).1,6,8 For example, condom availability at bathhouses and sex clubs is nearly universal.9 Although there has been no study demonstrating conclusively that bathhouse closings cause patrons to go to other places, the data are quite clear that men who engage in UAI already go to multiple venues; thus, when bathhouses are closed, the same behavior is most likely displaced to other settings,6 where there is inadequate condom availability (eg, places where sex is not expected to occur, such as parks, or places where management needs to avoid the appearance that it supports sex on the premises, such as adult bookstores). In another analysis of the UMHS 1997 data, we found that despite a wide variation across the 4 cities (Chicago, Los Angeles, New York, and San Francisco) in regulating where and what type of sex can occur inside bathhouses, overall rates of risk behavior among bathhouse patrons (operationalized as UAI with a nonprimary partner) did not vary across cities.8 These results suggested that bathhouses that prohibited risky behavior inside the bathhouse, such as in San Francisco, did not eliminate risky behavior but instead displaced it to other public or private settings. Moreover, the bathhouse exit survey cited previously2 found a significantly higher prevalence of UAI in a private setting (ie, home or hotel room) than in a public setting (including bathhouses and other public sex venues) during the prior 3 months (21.4% vs. 12.5%).
Compared with bathhouses, other public settings are typically less formal and less controlled,10 so closing bathhouses may displace sexual behavior to settings less prepared to support safer sex. For example, New York has had the most aggressive bathhouse and sex club closure policy of any city in the United States. In 1980, 22 bathhouses and sex clubs operated in New York,11 but only 4 operate there today. The enforcement of the New York bathhouse policy seems to have spurred a proliferation in that city of sex parties (held in hotels, warehouses, or homes and advertised by means of newspapers, word of mouth, fliers, and the Internet). In 2001, we enumerated listings of bathhouses (including sex clubs) and sex parties (excluding parties listed as taking place at sex clubs) for each of the 4 UMHS 1997 cities (Table 1). Although the total number of sex settings (ie, sex parties and bathhouses) in New York is relatively unchanged since 1980 (sex parties as we conceive of them today did not exist in 1980), by 2001, only one third were regulated bathhouses. A statistical comparison of the proportion of sites listed as sex parties versus bathhouses confirmed that New York had a significantly higher proportion of sex parties than the other 3 cities (χ2(1) = 9.60, P = 0.0033). A more recent enumeration in accordance with the same procedures (see Table 1) shows that some bathhouses have closed in all 4 UMHS 1997 cities since 2001, although not to the same extent in the non-New York cities, and that the ratio of sex parties to bathhouses in New York has increased further to three quarters of the sex settings. For the 2007 data, the direct New York versus non-New York comparison also yielded a significant χ2 test result (χ2(1) = 8.32, P = 0.0039). Although the evidence is indirect, taken collectively, these results suggest that when New York closed the bathhouses, entrepreneurial New Yorkers opened alternative facilities. Because these sex parties often are unlicensed businesses without a fixed location, they are less accessible to regulators and community-based organizations, thus inhibiting HIV prevention efforts such as condom distribution.12,13
The model provided by Faissol and colleagues1 that predicted a specific scenario in which closing bathhouses could result in a lower attack rate was based on 2 assumptions (a resultant increase in condom use and decrease in number of sex acts) that are not supported by the available evidence. Nevertheless, other public policy options are available, because as many investigators have pointed out, bathhouses provide an environment in which to reach the riskiest segment of MSM with HIV prevention messages and interventions.
William J. Woods, PhD
Diane Binson, PhD
Lance M. Pollack, PhD
Torsten B. Neilands, PhD
University of California San Francisco Center for AIDS Prevention Studies San Francisco, CA
1. Faissol DM, Swann JL, Kolodziejski B, et al. The role of bathhouses and sex clubs in HIV transmission: findings from a mathematic model. J Acquir Immune Defic Syndr
2. Woods WJ, Binson D, Blair J, et al. Probability sample estimates of bathhouse sexual risk behavior. J Acquir Immune Defic Syndr
3. Van Beneden CA, Modesitt S, O'Brien K, et al. Sexual behaviors in an urban bathhouse 15 years into the HIV epidemic. J Acquir Immune Defic Syndr
4. Richwald GA, Morisky DE, Kyle GR, et al. Sexual activities in bathhouses in Los Angeles County: implications for AIDS prevention education. J Sex Res
5. Disman C. The San Francisco bathhouse battles of 1984: civil liberties, AIDS risk and shifts in health policy. J Homosex
6. Binson D, Woods WJ, Pollack L, et al. Differential HIV risk in bathhouses and public cruising areas. Am J Public Health
7. Farley T. Cruise control: bathhouses are reigniting the AIDS crisis. It's time to shut them down. Wash Mon
8. Woods WJ, Binson D, Pollack LM, et al. Public policy regulating private and public space in gay bathhouses. J Acquir Immune Defic Syndr
9. Woods WJ, Binson D, Mayne TJ, et al. HIV/sexually transmitted disease education and prevention in US bathhouse and sex club environments. AIDS
10. Woods WJ, Binson D. Public health policy and gay bathhouses. J Homosex
11. Woods WJ, Tracy D, Binson D. Number and distribution of gay bathhouses in the United States and Canada. J Homosex
12. Halkitis PN. Redefining masculinity in the age of AIDS: seropositive gay men and the “buff agenda.” In: Nardi P, ed. Gay Masculinities
. Newbury Park, CA: Sage; 1999:130-151.