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Read the full text of this open letter below, from two researchers at the University of California San Francisco's Center for AIDS Prevention Studies to NYC Health Commissioner Frieden (r) regarding his hardline, and misguided, misinformed, approach to bathhouses.
January 16, 2008
Thomas Frieden, MD MPH
Commissioner
Department of Health and Mental Hygiene
New York City
RE: Policy Regarding Bathhouses and Other Commercial Sex Venues in New York City
Dear Commissioner Frieden:
In the last week we received several emails concerning a story in Gay City News related to a report addressing public health policy in bathhouses and other venues. As two researchers published in this area and cited in the report, we have a responsibility to comment. Because the overall thrust of literature does not support the conclusions drawn in the report, we write this open letter to correct any misperceptions the public may have acquired from reading the report and to ensure that your department has the opportunity to formulate policy decisions based on the available data.
The report’s summary of the literature was often incomplete. For example, it is technically correct to say, “Bathhouses attract high-risk clients” [1]. But because most people are unfamiliar with these environments, it easily creates a misperception equivalent to saying, “bars attract alcoholics.” The available data consistently show that the typical bathhouse client does not have unprotected anal sex at the bathhouse [1-7]. Most importantly, men at high-risk go to many venues for sex [1] and their high-risk behavior is most likely to occur at home [7]. Further, it is a small minority of men who engage in high-risk sex at the bathhouse; while the majority of men engage in behaviors that promote a social norm of safer sex.
The report cited published statistics but did not present the overall findings from cited studies. For example, the report cited two statistics from our bathhouse exit survey [7]. By saying that 11% of the men report unprotected anal sex and that the average number of partners at the bathhouse was 3.2, the report implied that there was a much greater level of risk-taking among bathhouse clients during a visit than the study data revealed. The report did not mention, as we discussed in the paper, that the 11% may overestimate the true rate of risk for HIVtransmission. Further, we stated in the sentence that presented the mean of 3.2 (as well as the median, 3.0, mode, 1.0, and range, 1-30), the figure represented only men who had oral or anal sexual partners. By excluding men who had zero partners (10%) and not mentioning that the majority (56%) of men did not engage in anal sex at all, the report significantly misrepresented the number of partners men had at the bathhouse and the overall risk that occurs there.
The report mentioned that “public health officials have been concerned that gay bathhouses and other commercial sex venues may facilitate spread of the infection.” Although a link can be established between men who frequent bathhouses and infection with sexually transmitted diseases, it is only a link, not a cause, because men who are likely to have an STD are likely to have to any number of places where men meet for sex [1]. Our exit survey data demonstrate how this might work: many of the men who reported unprotected anal sex during the previous 3 months did not engage in the behavior during the visit and men who engaged in unprotected anal sex did so wherever they had sex [7]. This finding was corroborated in a mathematical modeling analysis using population-based data from the Urban Men's Health Study that included four U.S. cities (New York, Chicago, Los Angeles and San Francisco), which showed that anal intercourse in bathhouses was more likely to involve a condom than the same behavior in other settings [8]. These results suggest that bathhouses, particularly those that promote consistent condom use, actually facilitate risk reduction. Regardless of local health policy, all bathhouses in the U.S. provide condoms [9, 10], thereby reinforcing condom use as a social norm.
Finally, the options for remedy presented in the report included only policies that generate antagonistic relations between health departments and owners with threats to close businesses that fail to control their clients' sexual behavior. The report did not include policies based on collaborative approaches in evidence across the country. Although the report stated that policy studies could not be found, such studies are available [11-18]. Using data from the Urban Men's Health Study, an analysis of local policy differences across New York, Chicago, Los Angeles and San Francisco suggested that policies made no difference in overall risk behavior, though they may have moved risk behavior elsewhere [15]. Moreover, published studies show that bathhouse may increase condom use [8] and that a collaborative relationship between a health department and a bathhouse resulted in an on-site HIV testing program that reduced risk behavior among testers [16-18].Scientific studies consistently conclude that bathhouses can be used to reach the small segment of the population responsible for transmission or at risk for becoming infected [1-8], and that over-regulating or closing bathhouse moves the behavior to other sex venues [15, 19]. But compared to other sex venues like parks and private sex parties (easily created over the internet in minutes), bathhouses and sex clubs are the most stable and secure locations where men go to meet for sex. A public health department, working with bathhouse management, can target at-risk men with interventions to help prevent the spread of infection, not just at the bathhouse, but whenever and wherever men have sex. Based on our data on policies in 12 health jurisdictions across the country,we draw two conclusions: 1) regulations limit prevention opportunities as they tend to generate antagonistic relations among stakeholder (i.e., health officials, club managers, prevention providers,and clients); and 2) policies that facilitate collaborative relations among stakeholder expand prevention opportunities, some of which have been demonstrated to reach at-risk men with prevention materials and interventions [9, 10, 16-18].
We wish you well in your efforts to tackle this complex situation and hope our response to the report will contribute to your department's policy review.
Sincerely,
William J. Woods, PhD
Associate Professor
Department of Medicine
Diane Binson, PhD
Associate Professor
Department of Medicine
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