C 2005)
Sex Roles, Vol. 52, Nos. 9/10, May 2005 (
DOI: 10.1007/s11199-005-3729-3
Accounting for HIV Risk Among Men on Methadone
Jorge Fontdevila,1,3 Nabila El-Bassel,2 and Louisa Gilbert2
This study explores accounts and reasons for engaging in HIV risk-taking behaviors reported
by heterosexual men in methadone treatment programs in the Harlem section of New York
City. A convenience sample of 62 men who reported having abused their female partners in
the past 12 months participated in 10 focus groups. Data analysis revealed four types of HIV
risky accounts, which we labeled nihilistic, hedonistic, fatalistic, and normative. The accounts
were rarely found in isolation, but were delivered in rich “performative” constellations. We
conclude that normative accounts in particular have important implications for HIV prevention. They show that the (hetero)sexual act is interactive “hard work” to say the least, and
condoms have no role interrupting it. In the end, the risks of losing masculine face before a
female partner are very much prioritized over long-run HIV risks.
KEY WORDS: AIDS; sociology of accounts; cultural narrative; heterosexual; HIV risk; methadone;
drug use.
Heterosexual women of color are among the
groups that are at increased risk for HIV infection in the United States (Amaro, 1995; Centers
for Disease Control and Prevention, 2003a, 2003b;
Goldstein & Manlowe, 1997; Karon, Fleming, Steketee, & De Cock, 2001; Kippax, Crawford, & Waldby,
1994; Zierler & Krieger, 1997). Women overall constitute an emergent part of the HIV/AIDS epidemic.
In 1992, women in the United States represented
about 14% of adults and adolescents living with
AIDS; by the end of 2003, this percentage had increased to 22%. Moreover, African American and
Latina women together make up about 25% of all
U.S. women, yet they account for 83% of AIDS diagnoses reported in 2003 alone (Centers for Disease
Control and Prevention, 2003a, 2003b, p. 1). Heterosexual contact is by far the primary source of HIV
infection among women, and at least one-third of
heterosexually-acquired AIDS cases in women are
ascribed to unprotected intercourse with an infected
male injection drug user (IDU) (Brown & Beschner,
1993; Centers for Disease Control and Prevention,
2003a, 2003b; Guinan & Hardy, 1987).
In addition, rates of intimate partner violence
among women in substance abuse treatment programs are two to three times higher than rates
found in general population surveys, which indicates
gender and power processes at work among drugusing groups that make it even more difficult for
women in intimate relationships to negotiate safer
sex and other forms of HIV protection (American
Medical Association, 1992; Bennett & Larson, 1994;
Browne, 1993; Gilbert, El-Bassel, Schilling, Catan,
& Wada, 1996; Morrill & Ickovics, 1996; Plichta &
Abraham, 1996; Wingood & DiClemente, 1997). It
is this picture of emerging HIV risk among ethnic minority women with drug using male partners
that calls for more intensive studies of how men
and women perform in intimate relationships. As
of yet, few researchers have examined these public health concerns from the men’s perspective. In
the present study we contribute to this knowledge
base by exploring the accounts and reasons for engaging in HIV risk-taking behaviors reported by heterosexual men in methadone maintenance treatment
1 Center
for AIDS Prevention Studies (CAPS), University of
California, San Francisco, California.
2 Social Intervention Group (SIG), Columbia University School of
Social Work, New York.
3 To whom correspondence should be addressed at Trayectos
Study (UCSF/CAPS), 4094 4th Avenue, Suite 202, San Diego,
California 92103; e-mail: jfontdevila@sdtrayectos.org.
609
C 2005 Springer Science+Business Media, Inc.
0360-0025/05/0500-0609/0
610
programs (MMTPs) who have recent histories of
partner abuse.
“Accounts” are story-like interpretations and
explanations that order and organize meaning in
social life. The concept of accounts was traditionally circumscribed to excuses for and justifications of
socially undesirable or deviant behaviors (Scott &
Lyman, 1968). More recently, account-making was
expanded to include any meaningful “means of weaving together disparate social events” in connection
with stressful or striking situations (Orbuch, 1997,
p. 457). In this view, both life crises and epiphanies
are made sense of via accounting. In fact, it can be argued that social identities and their sense of continuity are generated and maintained by endless creative
and indexical accounting (Auer & Di Luzio, 1992;
Lucy, 1993). It should be emphasized that accounts
and account-making include not only narrative storylines to protect the self but also culturally embedded
normative expectations and interpretations. Through
the study of ex post facto accounts, collective understandings of prescribed and proscribed ways of acting
and thinking can be analytically revealed. In short,
accounts provide a link between culture and individual motives. They show how social actors “align”
their individual behavior with culturally sanctioned
narratives to restore meaningful order in their social
interactions. Such circulating cultural narratives are
always more or less implicit in the construction of
these individual accounts.
In the case of HIV risk-taking, individuals often
“account” for sexual or injecting behaviors that can
be deadly in connection with HIV infection by aligning those behaviors with broader cultural scripts and
“recipes for action” that offer a sense of meaningful direction (Bloor, 1995; McKeganey & Barnard,
1992). These “recipes for action” are constantly updated and drawn from the collective culture within
which individuals interact. Most individuals have access to a rich and wide variety of circulating cultural
narratives that enable them to construct more or less
consistent accounts of their risky behaviors. In fact,
diverse articulations and constellations of these cultural narratives may have very different implications
for the transmission of HIV.
In this light, phenomenological and dramaturgical approaches to social action have guided the
interpretation of our study findings (Bloor, 1985,
1995; Bloor, McKeganey, Finlay, & Barnard, 1992;
Dingwall, 1976; Garfinkel, 1967; Goffman, 1955;
McKeganey & Barnard, 1992; Schutz, 1970). According to these theoretical perspectives, social actors in
Fontdevila, El-Bassel, and Gilbert
everyday life work hard at successfully maintaining
a sense of interactional continuity with each other.
They perform toward each other by feeling accountable to significant absent audiences and by switching between the front and back stages of their selves
in light of subtle but shifting framings or relevances
of the interaction itself. To get the task done and
guide their behavior, they use or compare their improvised situations to rich constellations of the different cultural narratives in circulation (i.e., a variety of stocks of knowledge, of expectations and
scripts, of recipes for action, of appropriate presentations of self). These interactional performances can
be more or less discursive or routinized depending
on the participating actors’ mutual assumptions of
their familiarity with the situation. Many cultural
narratives, especially complex narratives about the
self, are experienced as everyday life routines, unless interactional junctures make them discursively
explicit. Phenomenological and dramaturgical approaches offer powerful analytical tools to understand how account-making and circulating narratives
articulate with each other in daily life. They shed
light on why subtle (or not so subtle) interactional
switches between HIV safe and unsafe behaviors occur in risky situations, and on how circulating narratives help make sense of such risky switches.
Other explanations of HIV risk behavior using
cultural expectations have been proposed in the literature. However, these culturalist models, in contrast
to dramaturgical and phenomenological ones, do not
bring enough complexity and malleability onto the
act of risk-taking. Some of these models theorize
“folk” perceptions of risk as a characteristic of local
cultural variation. For example, in anthropologist
Mary Douglas’ (1985, 1992) view, some cultures are
more risk-prone (or, conversely, risk-averse) than
others according to various degrees of cultural conformity and social integration. However, Douglas’
own application of her model to HIV risk has been
criticized for being too rigid and static in the allocation of risk cosmologies, in particular her reification
of “drug addicts” in what she defines as isolated
“fatalists” (Bellaby, 1990; Bloor, 1995; Douglas &
Calvez, 1990; Johnson, 1987). These culturalist
models seem to neglect a much wider diversity of
circulating cultural narratives that are involved in the
making of HIV risk-related cosmologies. Thus, for
example, fatalistic narratives of inevitable HIV infection among “drug addicts” do not act in a vacuum
but in complex articulation with other everyday cultural narratives on normative ways of presenting the
Accounting for HIV Risk Among Men on Methadone
gendered or masculine self. Moreover, rigid culturalist models overlook the contextualized switches
among different, sometimes contradictory, cultural
narratives that individuals activate (or deactivate)
during HIV risk-taking episodes according to various relevant situations or even life-course stages. In
many instances, for example, overarching so-called
“risk-prone” cosmologies carried by social actors
into a risky situation may be less influential for
HIV transmission than sudden phenomenological
negotiations and power asymmetries of the (micro)situation itself. Thus, cultures or subcultures
should not be construed as either monolithically
risk-prone or averse. In any particular HIV risky
episode, individuals draw on a variety of cultural
narratives to make sense of their risky behaviors;
some of these circulating narratives are local, but
others are more widespread and global.
The purpose of this article is to distill and map
out the different overlapping accounts reported by
heterosexual men in MMTPs that make sense of their
HIV risk behaviors. Through the analysis of these accounts, the cultural narratives that circulate among
these men and that inform their account-making
were unveiled. Using rich qualitative data generated
by 10 focus groups, we explored the various types of
rationalizations and justifications that these opiatedependent men tell and retell themselves and others
in connection with their HIV risk-taking behaviors.
The HIV-risk account-making typology presented in
this article offers a subset of all possible cultural narratives from which these men draw their meaningful building blocks to construct their risky accounts.
In this sense, the qualitative unveiling of the cultural
narratives used by these men to justify their risky
behaviors has important implications for HIV/AIDS
prevention and intervention. Knowledge of the diversity of such accounts and narratives can help to
improve the design of more specific programs targeted at this particular risky population.
METHOD
Recruitment, Screening Measurement,
and Eligibility
Study participants were recruited from four
methadone clinics in Harlem, New York City, from
May 1999 to July 1999. Recruiters handed out flyers
about the study to potential male participants in the
waiting rooms of the methadone clinics. Participants
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were also referred to the study by the clinic staff. A
total of 408 men were recruited and agreed to participate in a 15 min screening interview.
The screening interview covered demographics,
drug use, sexual behavior, HIV risks, length and type
of intimate relationships in the past year, and the
physical aggression and sexual coercion subscales of
the Revised Conflicts Tactics Scale (CTS2; Straus,
Hamby, Boney-McCoy, & Sugarman, 1996). The
physical aggression and sexual coercion subscales
measure the extent to which intimate partners have
engaged in minor and severe physical or sexual attacks on one another during the past 12 months. The
purpose of this brief interview was to determine eligibility for participation in focus groups and in-depth
interviews to explore contextual meanings and mechanisms that link partner violence and HIV.
To be eligible for a focus group, a participant
must have: (1) been over 18 years old; (2) been enrolled for at least 3 months as a patient in a MMTP;
(3) during the previous year, had an ongoing sexual or romantic relationship that lasted for at least
3 months with a woman whom he considered his girlfriend, wife, common-law wife, or female lover; and
(4) during the previous year, perpetrated a violent
act, as measured by the physical aggression or sexual coercion subscales of the Revised Conflict Tactics
Scale, on any of his female partners. A maximum of
three intimate partners per participant was elicited.
Of the 408 men recruited, 101 (24.8%) were eligible
for the study. Of those eligible, 62 men (61.4%) participated in 10 focus groups from May to July 1999,
averaging 6 participants per group (range: 4–10). Participants received compensation of $25 for participating in the focus group.
Sample Characteristics
The mean age of the focus group participants
was 40.9 years (SD = 6.6), and their mean education level was 11.4 years (SD = 1.5). The majority
were Latino (48.4%, n = 30) and African American (37.1%, n = 23). Of the total sample, almost
three-quarters (72.6%, n = 45) were currently unemployed, one-quarter (25.8%, n = 16) had been homeless in the past year, almost one-half (45.2%, n = 28)
had not had money to buy food at some time in
the past year, and over two-thirds (71.0%, n = 44)
had received some type of public assistance in the
past year. Over one-fourth (29.0%, n = 18) had spent
some time in prison in the past year.
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Of those who had drunk alcohol in the past
6 months (61.3%, n = 38), almost two-thirds (63.2%,
n = 24) had become intoxicated. One-half of the
sample (51.6%, n = 32) reported having used heroin
in the past 6 months. Two-fifths (41.9%, n = 26) had
used cocaine, and one-fifth (21.0%, n = 13) had used
crack in the past 6 months. Finally, over one-fourth
(27.4%, n = 17) had injected some type of drug in
the past 6 months.
One-fifth (21.0%, n = 13) had had more than
one intimate partner in the past year. The vast majority (95.2%, n = 59) reported having perpetrated
some type of minor physical abuse to at least one
partner, and almost one-half (45.2%, n = 28) reported having perpetrated severe abuse. Two participants (3.2%) reported having used force or the threat
of force to make a female partner have some kind of
sex interaction.
Focus Group Methodology and Protocol
We conducted 10 focus groups, each of which
lasted approximately 2 hr. During the first 15 min,
we reviewed the consent form, including discussion
of the purpose of the study, confidentiality procedures, and participants’ rights. The institutional review boards of the participating MMTPs approved
the protocol for this study. All focus groups were
audiotaped.
Three male researchers were present during the
focus group sessions. One facilitated the focus group,
a second was in charge of reading consent forms and
logistics, and a third took notes and read a short
summary of the discussion at the end of the session. The first author facilitated 7 of the 10 focus
groups. At the completion of each focus group session, both the facilitator and the notetaker completed
post hoc questionnaires that assessed group rapport
and overall communication (e.g., who were the major
communicators, whether various speech styles were
used: clear, dispersed, respectful, rich), group dynamics (e.g., whether participants knew each other previously, whether they were engaged or disinterested),
and content coherence (e.g., whether there was overall consensus or significant disagreements).
Following methodological guidelines set forth
by Morgan and Krueger (1997), we organized the
focus groups around introductory, transitional, key,
ending, and evaluative questions. The facilitator
opened the focus group by introducing the general
topic of discussion to foster conversation among par-
Fontdevila, El-Bassel, and Gilbert
ticipants and then transitioned the group to key questions. The core of the discussion consisted of 8–10 key
topical questions and probes. The last 10 min were
devoted to asking the participants for the points they
thought most important, whether we had missed anything from a short summary given by the notetaker,
and their advice to improve future groups.
We prioritized topic specificity over saturation
by designing three different types of focus groups,
each of which explored one of three analytical areas
of interest: Type A, B, and C. Four Type A focus
groups explored the relationship between sex-related
HIV risks and violence in intimate relationships;
three Type B focus groups explored HIV risks and
sexual violence; and three Type C focus groups
explored HIV risks and drug violence. The design
of these analytical areas of interest was guided by
feminist and ecological theories and by our own
previous research.
Type A groups focused on conflicts over condoms that may arise in intimate relationships, hypothetical reactions to a request for a condom by
an intimate partner, when it feels right to stop using condoms in an intimate relationship, STD and/or
HIV disclosure in the intimate relationship, and solutions to avoid physical conflicts over condoms and
STDs in the couple. Type B groups focused on men’s
and women’s different sexual drives and potential
conflicts, hypothetical reactions to a refusal for sex
by a female intimate partner, when a “no” is really
a “no,” issues of sexual performance and substance
abuse, and monogamy’s “double standard” for men
and women. Type C groups focused on potential conflicts over drug splitting, sharing, and procurement
in the intimate relationship, attitudes toward sharing
needles in the couple, hypothetical reactions over refusal by female intimate partner to share needles, and
solutions to avoid physical conflicts over drugs in the
couple. Across the three types of focus groups, study
participants expressed many overlapping and intersecting accounts and rationalizations for engaging in
HIV risks. Because no obvious relationship between
type of account and type of focus group was found, all
qualitative quantifiers (e.g., most, many, some, few)
used in this study to report proportions of participants are based on all 10 focus groups as a whole.
Data Analysis
Focus group data were analyzed by the authors using a modified version of grounded theory
Accounting for HIV Risk Among Men on Methadone
(Emerson, Fretz, & Shaw, 1995; Glaser & Strauss,
1967) and following methodological guidelines set
forth by Morgan and Krueger (1997). First, audiotapes of focus group sessions were transcribed verbatim. These transcripts were all subject to revision
and quality assurance checks. Second, transcripts and
post-hoc process assessments were read carefully to
get a rough sense of the “big picture” and to recognize dynamics, preliminary patterns, and conceptual
comparisons. Third, analytical coding of the transcripts began at two levels: open-coding or line-byline analytical reading of the transcript to identify
and formulate unexpected ideas, themes, and/or issues close to the “raw” data; and focused-coding in
which priority was given not only to research questions and analytical interests but also to bottomup themes and issues that stemmed from the opencoding. A “thematic tree” with growing branches
that followed core themes and subthemes was progressively created. Selective coding was used by first
coding Type A focus groups, then Type B, and then
Type C, and by building up successively as we moved
along from one group type to the next. Continuous communication flow among the three authors in
frequent working meetings ensured conceptual standardization of the thematic tree and other reliability issues. Differences regarding thematic areas and
domains were resolved by consensus of all three authors. Fourth, at any stage of the analytical process,
memos that captured ideas and insights were written
to clarify and integrate the various thematic findings.
Fifth, in a final effort at synthesis, major thematic
branches and subbranches were linked in various explanatory stories or arguments. Focus group passages
and quotations were selected for this article because
they were either representative (i.e., opinions held by
a majority of participants) or illustrative (i.e., relevant examples) of important thematic findings. Qualitative analysis software package QSR-NUD∗ IST4
was used to aid in the processing and classification of
all analytical coding and to facilitate conceptual comparisons within the thematic tree.
Limitations of the Method
The focus group findings presented here are
meant to be suggestive. Convenience sampling procedures and small sample size render these qualitative data not widely generalizable. The typology of
HIV risk-taking accounts presented here is preanalytical and based primarily on face-value similari-
613
ties (analogy) rather than origins (homology). Because the study sample was self-selected, we do not
claim that the typology presented here is exhaustive of all possible risky accounts that exist among
men in MMTPs. Moreover, we do not claim propositional truth or falsity of what “really” went on in
the various behavioral and accounting claims, but
simply “post-hoc” rationalizations of action from the
point of view of the life-world of the focus group
participants. Thus, for example, the “true” motivational reason why an individual scapegoats a condom
for his failed erection in the context of casual sex
is unattainable with focus group methodology. However, the fact that the individual perceives, and many
others in the group agree, the condom as the cause
of his failure to perform sexually, that is to live up
to his masculine self-image, is highly consequential
for HIV/AIDS intervention research and prevention.
Finally, we did not separate men into distinct focus
groups based on ethnicity or race. In this connection,
we cannot explore in this article how race relates or
interacts with account-making and reasons for engaging in HIV risk behaviors.
RESULTS
Four analytical types of HIV risk-taking accounts emerged from qualitative analysis of the focus
groups of the study sample (see Table I): (1) Nihilistic
accounts; (2) Hedonistic accounts; (3) Fatalistic accounts; and (4) Normative accounts. We emphasize
that these accounts are ideal types and rarely found
in isolation in the real world. In fact, constellations of
multiple and sequential accounts and corresponding
cultural narratives that work in tandem are the empirical norm in everyday life, such as, for example,
combinations of hedonistic and normative types, or
combinations of nihilistic and fatalistic types, etc.
Nihilistic Accounts
We characterize nihilistic accounts as personal
stories that make sense of HIV risk-taking behavior
by drawing on collectively sanctioned narratives of
drug-dependent lifestyles. These cultural narratives
define drug-dependent lifestyles as desperate, senseless, and self-destructive. In the episodes that are the
object of nihilistic accounts, HIV risks may be accurately estimated or even alarmingly overestimated
(false pessimism) by individuals. However, for all
Table I. HIV-Risk Account-Making Typology That Emerged From the Focus Group Qualitative Analysis
Account
Nihilistic
Cultural narrative
Drug-dependent lifestyles are desperate
and self-destructive
Account subtype
Drug dysphoria
Pleasure and euphoria are blind and
impervious to consequences
Normative
HIV infection is part of fate or grand plan
beyond individual agency
Scripts/rituals that
inform face-to-face
presentations of
the self
A man should be sexually
in control, please
women, and have full
erections
Sex should be healthy and
condoms signal
disease/promiscuity
Monogamous couples
should be faithful and
condoms signal infidelity
Motivational mechanism
Future irrelevant
Future time discounting
HIV risks irrelevant or
even desirable
Path-dependent devalued
life expectations
“In the heat of the moment”
“Not to miss that opportunity”
“Not in the right state of mind”
“Drugs made me so horny”
Future irrelevant or False
optimism
Future irrelevant or False
optimism
Future time discounting or
Wishful thinking
Future time discounting or
Wishful thinking
Love as sacrificial
destiny
Invulnerable fate to
disease
“Till death do us part”
HIV heuristics irrelevant
“Thin” forms of reasoning
“I ain’t gonna get it”
“Faith of God”
HIV heuristics irrelevant
“Thin” forms of reasoning
Presentations of the
masculine self
“My way or the highway”
“Women like raw sex”
“Condoms don’t make a full man”
False optimism or Future
irrelevant if face-loss
(shame/anger)
Wishful thinking or Future
time discounting
Presentations of the
healthy self
“I ain’t nasty, don’t got no
disease”
“Men ashamed to buy condoms”
“Condoms create mistrust in the
relationship”
False optimism or Future
irrelevant if face-loss
(shame/anger)
False optimism or Future
irrelevant if face-loss
(shame/anger)
Wishful thinking or Future
time discounting
Sexual arousal
Drug and alcohol
euphoria
Fatalistic
HIV risk heuristics
“Dope sick”
“Cocaine hyped up”
“The death wish of addicts”
“The world owes me something”
Life’s diminished
marginal utility
Hedonistic
Emic label
Presentations of the
faithful self
Wishful thinking or Future
time discounting
Accounting for HIV Risk Among Men on Methadone
practical purposes such heuristics become irrelevant
in guiding a man’s behavior because: (1) feelings of
drug dysphoria, cravings, and/or sheer pain typically
reach an emotional “point of no return” where preference for own and other’s future well-being is heavily discounted; and/or (2) future quality of life may be
perceived as having negligible marginal utility among
hard-core drug users. In other words, when all material and symbolic resources to invest in future wellbeing are gone and depleted, one more tomorrow is
simply more of the same “hell.”
It should be noted that even in these nihilistic episodes where agents seem to discount the future completely, their “reward” function (i.e., demand for drugs) is never completely price-inelastic.4
Thus, drug-dependent individuals can and do moderate the intensity of their drug cravings according to
various available cognitive beliefs or other imminent
risk factors in their surroundings, such as the fear of a
police raid in the neighborhood, which may prevent
them from going out to buy drugs, or the suspicious
quality of a drug just purchased from an unknown
dealer, which must be tested in patient and slow
doses, etc. In fact, there is a wealth of literature on
the “price elasticity” of alcohol, nicotine, and other
drug addictions (Edwards, 1994; Elster, 1999; Orford,
1985). However, it became clear from the cultural
narratives that circulated among the focus group
participants that drug cravings, especially those due
to heroin withdrawal, were considered to be essentially price-inelastic. In short, most accounts of nihilistic HIV risk-taking among participants draw and
legitimize themselves on such price-inelastic drug
narratives.
We found two subtypes of nihilistic accounts in
the qualitative analysis of our focus groups interviews
(see Table I): (1) drug dysphoria, and (2) life’s diminished marginal utility.
Drug Dysphoria: Dope Sick
In this connection, at least two types of drug
dysphoria have been experienced by the study sample: (1) heroin withdrawal, and (2) cocaine craving.
4 “The
demand of a good is said to be totally inelastic if the same
amount is bought regardless of price (on the assumption that the
total cost is within the consumer’s budget). If a price increase
causes less of a good to be bought (under the same assumption),
the demand is said to be elastic. Thus a diabetic’s demand for
insulin might be totally inelastic, whereas normal consumer demand for chocolate is highly elastic” (Elster, 1999, p. 168).
615
A general theme that appeared frequently was that
avoiding heroin withdrawal or the “desperation of
getting straight” makes a person engage in serious
HIV risky acts, such as sharing dirty needles. In this
line, many participants across all focus groups talked
about their risky experiences during heroin withdrawal or when “dope sick.” Some of the most extreme ones are worth mentioning here, such as using
dirty water by the railroad tracks to rinse and prepare
the heroin “fix,” using rainwater from dirty puddles
for the injection solution, or using disposed syringes
from the street that have blood inside them. One participant summarized these generalized views as follows: “When I’m dope sick, I want to get off. You tell
me you got AIDS, I don’t give a fuck, I’m dying now.
I’m dope sick.” Another insisted that, when he is seriously dope sick, “if that was the only set of [dirty
syringe and cooker] works that was there, I take a
shot and use it.”
Cocaine Hyped Up
Regarding cocaine cravings and HIV risks, one
focus group participant clearly summarized what
other cocaine users had expressed as well that “when
people shoot cocaine, once they’re hyped up they
don’t care about a clean set of works. They don’t care
about nothing. They’re paranoid. They want to get
the next shot . . . and there is no needle cleaning.”
Life’s Diminished Marginal Utility:
The Death Wish of Addicts
Another set of self-destructive nihilistic accounts of HIV risk-taking reported by these men
in MMTPs related to their overall life’s diminished
marginal utility, or in participants’ (“emic”) terms
“the death wish of addicts.” One participant in nihilistic desperation expressed that “sometimes in the
back of my mind, I kept shooting drugs to perhaps get
that AIDS. I wanted to die . . . I thought it was a blessing. AIDS kills. There’s a lot of people . . . you know,
that are fucked up, and I’m one of them.” Another
said: “I’m always going to be a junkie no matter what,
and the type of attitude we have . . . is that we don’t
care. It’s like a death wish to us.” For many participants across all 10 focus groups, addicts “have a sense
of a suicidal tendency,” are “tired of living,” or have
a “don’t give a fuck” kind of attitude. In general, they
“don’t care about themselves. They don’t care about
616
getting sick. They don’t care about HIV.” At least
one participant implied that drug lifestyles do not
cause nihilism, rather it is the other way around: “All
addicts have a suicidal tendency. That’s why we’re
addicts, you see.”
The World Owes Me Something
An interesting variation of these nihilistic
themes of self-destruction was related to a shift in the
intentional object of the destructive behavior, from
self to others. Thus, according to quite a number
of participants, besides being self-destructive many
people infect others with HIV out of rage or revenge.
One participant told the story of an HIV seropositive woman he personally knew who willingly spread
AIDS; she was “angry and she wanted to take it out
on another person . . . she’s like ‘fuck it, you’re going to have it.”’ Another participant knew a woman
who was infecting everybody because “she was getting back at men because she got abused by men
so much . . . ” One participant concluded that some
people that contract HIV “become miserable . . . they
feel as though the world owes them something, so
they go out intentionally to spread it.” It is interesting
that “The world owes me something” was an account
typically reported in reference to desperate women.
Hedonistic Accounts
We characterize hedonistic accounts as personal
stories that make sense of HIV risk-taking behavior
by drawing on collectively sanctioned narratives of
pleasure and euphoria. These cultural narratives define pleasure and euphoria as blind and impervious to
consequences. During the episodes that can elicit hedonistic accounts two things can happen: (1) an individual’s future safety becomes irrelevant, or (2) HIV
risks are hopelessly underestimated (false optimism).
Two possible motivational mechanisms may be at
play: (1) in this case, intense feelings of drug euphoria and/or sexual arousal may reach an emotional
“point of no return” in which preference for own
and other’s future well-being is heavily discounted;
and/or (2) “wishful thinking” processes where drives
shape beliefs, such as when intense sexual desire distorts HIV risk perception to suit an individual’s comfort level of safety. For example, an individual may
become so aroused by a sexy one-night-stand that
he wishfully thinks it is fairly safe to perform unprotected sex if only just once. However, in his proba-
Fontdevila, El-Bassel, and Gilbert
bilistic assessment, this individual has conveniently
overlooked the fact that he has had quite a number of
“only-just-once” unsafe partners in his recent past. In
short, most accounts on hedonistic HIV risk-taking
among participants draw and legitimize themselves
on such narratives of blind euphoria and arousal.
We found two subtypes of hedonistic accounts
in the qualitative analysis of the focus groups (see
Table I): (1) sexual arousal, and (2) drug/alcohol
euphoria.
Sexual Arousal: In the Heat of the Moment
Most participants across all focus groups expressed the idea that “people know the risk is there
but sometimes in the heat of the night . . . shit happens.” Similarly, “in the heat of the moment, your
foreplay is already gone and the condom goes to
hell.” The expressions “in the heat of the moment”
or “in the heat of the night” were used again and
again by focus group participants in connection with
taking HIV risks. When they were asked to define
it, a focus group participant responded: “The passion
is stronger than the passion of being safe.” Another
participant was also very illustrative: “[HIV] education is good . . . but most of the guys, for example me,
when I get horny . . . I’ll stick anybody besides men.”
Other powerful rhetorical expressions in connection
with arousal and unprotected sex were: “Once legs go
up, your whole mind goes blank,” “[men] are thinking with their ‘dick’ head instead of their ‘big’ head,”
or sex without condoms is like “playing the Russian
roulette.”
Not to Miss That Opportunity
A related theme that came up several times in
many focus group discussions was the notion that
beautiful and sexy women are hard to come by.
Therefore, once a man gets a beautiful woman in bed
it becomes too costly to miss that opportunity just
because condoms are not around. Thus, one participant in connection with HIV risk-taking and beautiful women said: “Because she look good . . . [you]
take a chance not to miss that opportunity.” Similarly, another expressed: “I would say [men] have
a few beers, you know if they drink a little bit and
they ain’t got a condom, [and] that’s the only chance
they’re going to get . . . to get that pussy . . . if I can’t
get it tonight, there might not be another chance
down the road.”
Accounting for HIV Risk Among Men on Methadone
Drug/alcohol Euphoria: Not in the Right
State of Mind
Most participants agreed that a drug high impairs thinking when it comes to HIV risks. Thus, a
widespread theme across all focus groups was that
people take HIV risks because they are not “in their
right state of mind . . . [they] may be high or fucked
up.” Or that one should “get rid of any bad thinking that gets you into that [sexual] situation because
when you use drugs and alcohol your thinking . . . you
ain’t there. Nobody can tell me that they can do their
best thinking when they’re under the influence . . .”
Similarly, safer sex when high is “more difficult for
me because you’re impaired. You don’t know half
the shit going on.” One participant indicated that under the influence of drugs you never know when to
stop pushing your partner for sex. Thus, when sober
“you might have found out [that she doesn’t want
sex] in the fifth try . . . but being high is going to take
10 for you to get it clear.”
Drugs Made Me so Horny
In addition to cue misreading and other cognitive impairments, drug and alcohol euphoria may
lead to HIV risk-taking because it is perceived to
enhance sexual drive, thus increasing rates of discounting future consequences of behavior and decreasing “point-of-no-return” emotional thresholds.
In one risky story, a participant high on cocaine and
knowing for a fact that his sex partner was HIV
seropositive engaged in unsafe sex: “I went with the
girl [to a hotel], we were hanging out. We had money,
you know, and then . . . you know, I even went to the
lobby to get a condom and said ‘fuck it, man,’ you
know, ‘cause when you’re getting high . . .” In short,
this participant traded his future well-being for an
imminent night of passion. Another participant explained that drugs made him so sexually aroused that
he forced his sex partner to have risky sex: “drugs is
what made me so horny and shit . . . I mean if it wasn’t
for the drugs maybe I would have stopped, but the
drug was pushing me more and shit.” In another story
of drugs and unprotected sex, “I did something that
was silly. I fucked a woman . . . with no rubber . . . I
was high . . . you do stupid things. I wouldn’t have
done that if I was sober.”
Hedonistic accounts are used by these men on
methadone to make sense of their HIV risk-taking
behaviors within the context of broader narratives of
617
“irrational” pleasure and euphoria. It should be emphasized, however, that behavioral and neurological
researchers have not found that euphoria and arousal
is “reward insensitive” or completely blind to behavioral consequences (Elster, 1999; Orford, 1985).
Thus, individuals interrupt passionate moments or
drug “highs” all the time if something more relevant
or dangerous comes up, from a sports game on television to an imminent life threat. In many instances,
culturally-sanctioned beliefs about the effects of alcohol and other drugs exempt individuals from moral
or agentic responsibility during addictive binges. A
kind of cultural “time out” where “irrational” behavior is more or less tolerated and even forgiven, as,
for example, exonerating a drunk husband when he
beats his wife. Similarly, individuals may feel less social pressure to keep up their HIV/AIDS protective
strategies during their addictive binges. In this connection, narratives that sanction drugs and sex as “irrational” and impervious to HIV consequences may
not so much reflect blind pharmacological or neurophysiological processes at work but cultural “time
outs” where any undesirable behavior can be legitimized later by blaming the drugs or sexual excitement (Kantor & Straus, 1987; Parker & Auerhahn,
1998).
Fatalistic Accounts
We characterize fatalistic accounts as personal
stories that make sense of HIV risk-taking behavior by drawing on collectively sanctioned narratives
of inevitable fate or sacrificial love as destiny. These
cultural narratives define whether one becomes HIV
infected as part of a foreordained plan that is beyond
individual agency. In the episodes that are the object of fatalistic accounts, HIV risks are not a matter
of concern, and can be either underestimated (false
optimism) or overestimated (false pessimism). In
any event, such heuristics become irrelevant in guiding safer behaviors because HIV infection is ranked
as subordinate to transcendental values outside the
agent’s control. It can be argued that in fatalistic
accounts the agent has adopted “thin” rather than
“broad” forms of rationality.5 Thus, the individual
5 According
to Elster (1999, p. 142): “First, for an action to be
rational, it has to be the best means of satisfying the desires of
the agent, given his beliefs. In itself, this is a very weak requirement. If I want to kill a person and I believe that the best way
of doing so is to make a doll representing him and stick a pin
through it, then according to this weak definition I act rationally
618
can be said to be rational (albeit “thinly” rational)
in that he properly aligns his actions (unsafe sex) in
agreement with his reasons (beliefs and wants) for
acting, namely, (1) his transcendental belief in invulnerable fate or sacrificial love, and (2) his desire to
be subsumed within those transcendental truths or
values. The agent in this case, however, does not act
“broadly” rational because his beliefs themselves are
clearly motivated and not transparently rational. In
other words, his beliefs do not build on independent
judgment of available evidence but are shaped by his
strong desire to belong to something “greater” than
himself, such as the values of love or fate. For example, in the simplest scenario, an individual may believe that he is invulnerable to HIV infection because
he feels chosen by God. He is rational in the “thin”
sense because he ignores HIV risks in accordance
with his belief that he is invulnerable to disease. To
be “broadly” rational, however, he would have to revise his belief of invulnerability systematically, and
conclude that no amount of faith in fate or God can
refute the available epidemiological evidence that
continuous exposure to HIV is highly correlated with
HIV seroconversion and, eventually, with AIDS.
We found two subtypes of fatalistic accounts in
the qualitative analysis of the focus group interviews
(see Table I): (1) love as sacrificial destiny, and (2) invulnerable fate to disease.
Love as Sacrificial Destiny: Till Death Do Us Part
A handful of participants across all focus groups
mentioned that AIDS is irrelevant if there is true
love. Thus, “I say to myself I really love that girl,
right? . . . you know, whatever her problem is, it’s
my problem too . . . they say it’s until death do us
if I make the doll and pierce it with a pin. We would hardly
be satisfied with this conclusion, however, not because homicidal desire is irrational (it may be immoral, but that is another
matter), but because my belief is transparently ill-founded. Second, therefore, we need to stipulate that the beliefs themselves
are rational, in the sense of being grounded in the information
available to the agent.” In short, the first type of rational action
takes beliefs for granted (“thin” form of rationality); the second
type of rational action grounds beliefs in the available evidence of
the age (“broad” form of rationality). However, we believe that
not even the most grounded of beliefs can be transparently rational throughout. There is always a higher-order taken-for-granted
horizon that escapes phenomenological definition. In this connection, rather than a strict dichotomy between ‘thin” and “broad”
forms of rationality, we propose the weaker claim of an epistemological continuum where beliefs may be located according to
whether they are more or less testable or falsifiable.
Fontdevila, El-Bassel, and Gilbert
part . . . if it happens to her, let it happen to me.” One
participant clearly maintained that the only way he
envisioned getting infected “would be out of love.”
Another was convinced that, even if he became infected with HIV, “I know my woman would stay with
me.”
One participant elaborated on these sacrificial
themes regarding sharing needles with his wife:
“That’s [my wife] who I’m going to be with the rest
of my life, . . . we know we’re going to be [together],
. . . if I’m going to get it [HIV], she’s going to get it,
you know what I mean?” Another participant continued to share needles with his wife even after he
found out she was HIV seropositive “because she’s
my wife . . . [and] we’ve been together all the time.”
This same participant took an HIV test just to let his
wife know that he was seronegative but that he would
keep sharing needles with her regardless, “you know,
I did it afterwards [take the test] to show my love.”
Invulnerable Fate to Disease: I Ain’t Gonna Get It
A number of focus group participants claimed
that some “people think that they can’t get
[HIV] . . . people think like they’re invisible or something.” Others added that some people think they
are “immune” to HIV. In this connection, one participant reasoned that because he had been with his
HIV seropositive wife practicing unprotected sex for
years and never got infected, “I’m still going to make
out [unsafely] or whatever. In my mind I know that
I’m not going to get it because I didn’t get it throughout the time that I was with her.” In another instance of inevitable fate, another participant stated
that: “either you had it then or you ain’t going to get
it at all, period. That’s all.”
Fatalistic accounts were clearly not as
widespread as the other account types, such as
nihilistic, hedonistic, or normative (see below). In
this connection, only one participant felt invulnerable to HIV because of his strong “faith of God.” It
is surprising that he was the only one in this focus
group sample to use a religiously-oriented fatalistic
account.
Normative Accounts
We characterized normative accounts as personal stories that make sense of HIV risk-taking behavior by drawing on collectively sanctioned narratives of the appropriate presentation of the social
Accounting for HIV Risk Among Men on Methadone
self. These cultural narratives offer prescribed and
proscribed scripts and rituals of presenting and saving the self’s face according to particular interactional events.6 In the episodes that are the object of
normative accounts, HIV risks are either (1) typically
underestimated (false optimism) or (2) due to faceloss, the emotions of shame and/or anger can distort
the future so that it becomes irrelevant. Two possible
motivational mechanisms may be at play: (1) “wishful thinking” processes where motives shape beliefs,
namely, the normative pressures to save face in an interaction may lead the social actor to underestimate
HIV risks in order to avoid breaching a scripted or
ritualized “working consensus,”7 a consensus about
what it means to behave in socially appropriate ways,
and/or (2) if indeed there is irreparable face-loss after
breaching a working consensus, the emotions of anxiety, shame, or even anger may reach a “point of no
return” where preference for own or other’s future
well-being is heavily discounted.
We identified at least three subtypes of normative accounts (see Table I): (1) presentations of the
masculine self, (2) presentations of the healthy self,
and (3) presentations of the faithful self.
Presentations of the Masculine Self:
My Way or the Highway
Most participants across all focus groups concurred that men “set the tone” in their sexual encounters. They said that men are about being “in control” of the situation. As a consequence, many men
are “hurt when denied sex” by their female partners.
One participant clearly expressed that to be denied
sex is a “toss up ‘cause you don’t know what might be
on a man’s mind when you be denied any sex.” Another participant mentioned how immature men can
be when they are denied sex: “We, as men, we think
we’re strong and that, but sometimes we get our feel6 According
to Goffman (1955, p. 222, 226), face is defined as “the
positive social value a person effectively claims for himself by the
line others assume he has taken during a particular contact” and
face-work is defined as “the actions taken by a person to make
whatever he is doing consistent with face.”
7 A phenomenological “working consensus” is what takes place in
social interactions to maintain face and avoid breaching scripted
common sense. According to Goffman (1955, p. 226), “it is typically a ‘working’ acceptance, not a ‘real’ one, since it tends to
be based not on agreement of candidly expressed heart-felt evaluations, but upon a willingness to give temporary lip service to
judgments with which the participants do not really agree.”
619
ings hurt and instead of knowing how to deal with it
in a mature way, we’re like little kids . . . running out
and going to get another broad to satisfy you is like
a little kid throwing a tantrum.” In connection with
his main partner requesting protected sex, one risky
participant admitted that it used to be “my way, you
know, or the highway. You know what I’m saying?
And not thinking about my loved ones . . .”
Women Like Raw Sex
Another set of themes was related to the notion that many men found pride in giving a woman
pleasure. Thus, several participants across the focus
groups expressed that they loved to satisfy a woman
sexually, for example: “I love to take my time and do
everything she asks me to . . .” or “I focus more on
satisfying her than myself . . .” One participant took
pride in giving his partner multiple orgasms in every sexual episode: “I’m a freak at that, I want to see
how . . . in what little time I can make a girl come as
fast . . . I don’t know why it drives me crazy.”
It is interesting that quite a number of focus
group participants believed that most women only
reached orgasm if they felt a man’s ejaculation inside, and that was why some women “have one male
use a condom but they have another male don’t
use condoms so they [women] get their climax.” As
a consequence, unprotected sex allows for orgasm
synchronization between a man and a woman because, according to the above view, it is only when
a man ejaculates inside a woman that she can reach
her orgasm. Put another way, “that helps [her] climax too . . . because if I climax . . . you know she’s
coming . . . that wetness, because as you are making
love, she is getting very wet inside . . . [and] you’re
getting more excited.” This “risky” belief (i.e., that
women only climax without condoms in direct contact with a man’s ejaculation) has significant consequences for the spread of HIV/AIDS, especially if
one of the components of the “masculine identity”
equation involves satisfying a woman sexually. One
participant summarized it this way: “Females want to
feel raw dick inside them . . . they tell you that [raw
dick] is part of the sex act . . . to feel the male.”
Condoms Don’t Make You a Full Man
Although some participants had a favorable attitude toward condoms, the overwhelming majority
620
across all of the 10 focus groups viscerally disliked condoms. One participant captured nicely this
widespread consensus by saying that a condom
“doesn’t make you a full man. I guess your ego, you
know . . . it does nothing for your performance.” Two
reasons emerged as to why men dislike condoms:
First, as with women, many participants thought that
condoms impaired sexual excitement by preventing
direct skin and fluid contact, “I don’t want to put
no rubber on, I want to go ahead and get your
skin . . . I like to feel that wet pussy . . .”; and second, for other participants, condoms impaired full
erections because they became a distraction during
sex.
In this connection, condoms were often perceived by participants to be related to their failure
to perform sexually by getting in the way of their full
erections. In other words, condoms let you down as
a full man. One participant expressed his concerns
by saying that “anything that interrupts when I’m
getting ready to make love, anything that interrupts
that process, I’ll lose my [erection] . . . you know, my
dick goes down like crazy, man.” Also, condoms always “seem kind of clumsy and like when you’re at
the moment when you’re with somebody you want
to have sex, you just want to get it on . . . dive right
in.” Another participant elaborated on the hassle of
putting on a condom during foreplay: “. . . because it
takes time to put it on . . .like when you’re doing foreplay, you might not stay erect the whole time. So you
can’t put it on before. And after you finish foreplay,
right, and you want to get into the [vagina] . . . you
got to stop and unroll this thing on your joint, and
it takes something away. . .” Other rhetorical phrases
in connection with putting on condoms and erection problems were: “I may be hard, by the time I
open that condom, I’m soft again,” “It’s the freaking rubber thing that’s doing it,” “it spoils the moment,” “your dick might go limp,” “you might not get
none.”
Many of the focus group participants expressed
how stressful it was to lose an erection during sex.
This was not so much because “once you lose it [the
erection], it’s hard to get it up again . . . [and] no matter how hard you try, that shit won’t get hard,” but
because a woman may imagine that her nonerected
man is having an affair with another woman or
even that he is gay. Thus, for example, one participant’s sex partner reproached him that “you couldn’t
get hard, because you’re with the other girl.” Another participant recalled several times getting high
on crack and losing his erection, and his woman
Fontdevila, El-Bassel, and Gilbert
“thought maybe I was gay or something . . . ‘You’re
gay!’ [she shouted].”8
In short, to maintain phenomenological consensus about what it means to be a “man,” arduous facework must be deployed to live up to the cultural
narratives of being in control of the sexual act, of
truly satisfying a woman, and of keeping a full erection. In this light, it is not impossible to understand
why for many men such demanding face-work can
easily compromise their use of condoms and other
forms of HIV-protective concerns. In addition, the
lack of normative pressures from significant others
experienced by these men on methadone regarding
condom use did not help either. Most participants
across all focus groups acknowledged that they never
talked about condoms and HIV protection with their
friends or “homeboys.” If anything, they only talked
about condoms with their counselors or doctors. In
fact, quite a few perceived their friends to engage in
riskier HIV behaviors than they themselves did. In
this connection, several participants said: “A lot of
my friends say fuck that, I don’t like using condoms,”
or “they [my friends] are still wild.” It is interesting that one participant claimed that even when his
friends said they used condoms, “I might not believe
them.” Moreover, other participants experienced direct normative pressures by relatives against using
condoms. For example, one participant explained
how “coming from a Hispanic family, I had a macho
image and I thought men that wore protection were
less than a man. I thought they didn’t know how to
do sex and they needed help. My whole perception
was wrong.” Ask about where he got that perception,
8A
few more remarks regarding condoms and erections are worth
reporting here. On the one hand, for quite a few participants erections were “a mental thing,” in that maintaining an erection during sex had to do more with their power of suggestion than anything else. For example, one participant reported that with some
women, those whom he perceived as risky or sick, he thought that
condoms had to be used no matter what, so “before you even
get high [you know] the condom got to be used, there won’t be
no sex without it. So you prepare yourself mentally for that condom action before that.” This participant implied that there are
no erection problems with condoms in a clear-cut scenario where
a woman looks like she is highly infective. On the other hand,
for other participants, maintaining an erection had to do with the
level of sexual attraction they felt toward their sex partner, “there
are some women . . . . [that] I got to put on a condom and there
goes the erection, but there are other women that I be with and
that I like so much that when I have sex with them, right, my shit
stays hard. I put on the condom with no problem. In other words,
as another participant said: “[erections] depend on the relationship you have [with] the woman and how the woman interests
you.”
Accounting for HIV Risk Among Men on Methadone
he said “I got it from my uncles and my dad . . . they
used to goof around [making fun of men who used
condoms].”
Presentations of the Healthy Self: I Ain’t Nasty,
Don’t Got No Disease
For many men of the study sample and their
female partners condoms were markers of sexually transmitted diseases, including HIV/AIDS. In
turn, sexually transmitted diseases signaled promiscuity and “moral” pollution, especially in the case of
women.9 In this connection, one participant reported
an incident with a casual sex partner in which he suggested that they use condoms, and she yelled at him:
“I ain’t nasty, don’t got no disease.” Unfortunately,
this breach of assumed healthy selves in sexual interaction was only repaired by dropping condoms altogether and overlooking HIV risks.
Men Are Ashamed to Buy Condoms
The phenomenology of healthy selves in connection with condom use intersected with private versus public face-saving concerns among these men in
MMTPs. Thus, a few participants across the focus
groups concurred that it was embarrassing to pick
up condoms in public from outreach workers on the
street because people could assume they were sick:
“after she [outreach worker] gives me some condoms, she’s probably going to think I’m sick . . .” A
few participants expressed the idea that some “men
are ashamed to buy condoms.” Also, “some men
are ‘acomplejados’ [Spanish for having an inferiority
9 It
should be noted that the “Madonna-Whore” Judeo-Christian
narrative that distinguishes between “loose” and “proper”
women was pervasive among these men on methadone. According to the opinions of most participants, it can be argued that
women were subject to two sources of moral pollution: (1) drug
pollution; and (2) sex pollution. In a powerful materialization of
such narratives, one participant explained that he stopped sexually forcing a “loose” woman when he realized that she was
a virgin. Thus, while she was resisting “I was feeling bad, I’m
saying but she is a hooker. . . [then I felt] I couldn’t [penetrate]
her. That’s when I realized that she was a virgin . . . I pulled out
and put my pants back up . . . I felt really bad afterwards.” In another example regarding who gets a larger share of drugs, “if it’s
your woman, you got a lot of respect for them ‘cause that’s your
woman. If it’s a street girl, it’s different . . . it’s just a whore from
the street.” In general, quite a number of participants took pride
in the fact that their wives or steady girlfriends had never been
drug users.
621
complex], for them it is kind of embarrassing to go
to the store [to buy condoms].” Moreover, for some
participants there was an association between condoms and homosexuality that was clearly stigmatizing in public: “it was a big deal to go to the drugstore
and buy condoms . . . [we thought it was related to]
gay things and stuff like that . . .” In this light, it can
be argued that the phenomenological “working pressures” to present a healthy face in sexual interaction
(but also in public) may lead some of these men and
their sex partners to engage in HIV risks.
Presentations of the Faithful Self:
Condoms Create Mistrust in the Relationship
Most focus group participants who were married or in monogamous relationships concurred that
requesting condoms creates serious mistrust in the
couple. In other words, for men in committed relationships, condoms were considered to be markers of
infidelity. Most participants expressed how shocked
they would feel if their monogamous partners were
to request a condom during sex. Thus, among various reactions, participants said that they would have
to “question her,” that “it creates some kind of mistrust [in the relationship] . . . she’s been going out
with somebody or she thinks I’ve been going out
with somebody,” that “it’s like I’m back in the prostitutes’ house or something. It’s very impersonal,” or
that “it would put a monkey wrench in our relationship.” Moreover, at least one participant strongly believed that, if condoms were brought up in an intimate relationship, “there is no reason to be in the
relationship . . . I don’t think it’s worth it.”
To face up to such demanding “monogamy
narratives” of conjugal fidelity, many unfaithful men
and women end up practicing unsafe sex with their
committed partners. The motivational mechanisms
behind the monogamous presentation of self are culturally quite complex but essentially involve shaping
HIV-risk perception to save a “faithful” face in the
relationship. At least two motivational possibilities
may be at play: (1) an individual may “conveniently”
believe that all his “affairs” outside his committed
relationship were HIV safe and therefore convince
himself that there is no need to protect his wife or
steady girlfriend from HIV; and/or (2) an individual
may “wishfully” think, based on very limited evidence, that his committed partner would never cheat
on him or her. The “denial” motivations behind the
latter rationalization can be several: for many men,
622
believing in a “good” and loyal wife means to be respected as a man in the community; for many women,
keeping a “good” husband is a symbol of status, etc.
(Sobo, 1993, 1995). In this line, the phenomenological “working pressures” to present a faithful face in
their intimate relationships may lead some of these
men on methadone to overlook HIV risks.
DISCUSSION
The results of the present study are important
because they bring more phenomenological and cultural complexity into the explanation of HIV risktaking behaviors. Our study participants reported
complex constellations of different cultural narratives that were in circulation in their social worlds—
narratives on the consequences of drug dysphoria or
euphoria, on the blinding effects of sexual arousal,
on sacrificial love in the relationship, on feeling invulnerable to disease, and on the appropriate presentations of the self in the course of intimacy.
Our findings suggest that to account for sexual and
drug-related HIV risks, these heterosexual men in
MMTPs tell and retell themselves and others rich
nihilistic, hedonistic, fatalistic, and normative stories
built on broader cultural narratives that give them a
sense of direction after the risky fact, a “why-thingshappened” account (see Table I). Nihilistic accounts
of HIV risk-taking make sense by drawing on beliefs of self-destructive and senseless drug-dependent
lifestyles. Fatalistic accounts surrender HIV infection to larger-than-life forces that are beyond the
individual’s control and sense of agency, such as
sacrificial love or invulnerable fate. Hedonistic accounts make sense of HIV risk in the context of
broader narratives of “irrational” pleasure and euphoria; they create “timeout” spaces where everyday logics disappear and give way to “liminal” spaces
of euphoria, the erotic, emotional embodiment, and
spontaneity (Davis, 1983; Monagham, 2002). Finally,
normative accounts anchor themselves in routine
and scripted rituals of social interaction between the
sexes; they build on the appropriate presentation of
the self in gendered, unpolluted, and monogamous
interactions.
Normative accounts have important implications for sex-related HIV/AIDS prevention. They reveal complex processes at the root core where the
social meets the sexual. For example, for many of
these men in MMTPs, safer intercourse threatens
scripted presentations of their masculine self: (1) be-
Fontdevila, El-Bassel, and Gilbert
cause complying to condom requests by a female
partner surrenders some of their control of the sexual act, (2) because condoms act as “dry” barriers
to a woman’s “wet” pleasures of feeling the “man,”
and (3) because putting on a condom implies disrupting spontaneity, which can impair erections. In other
words, to maintain an appropriate working consensus
of what it means to be a “man,” arduous face-work
must be deployed in many of these men’s gendered
interactions and performances to live up to cultural
narratives of being in control, of satisfying a woman,
and of keeping a full erection (Butler, 1990; Connell,
1995; Gilmore, 1995). This is interactive hard work,
to say the least, and condoms have no role interrupting it. In the end, the social risks of losing masculine
face in front of a female partner, including embarrassment and humiliation, are very much prioritized
over long-run HIV risks.
Moreover, the use of condoms in certain casual
contexts can be interpreted as sexual exchanges between selves that are unhealthy and promiscuous.
In particular, the tricky associations among disease,
condoms, and sexual promiscuity are highly stigmatizing for women, and they spill over into symbolic
realms of moral pollution, as they signify historically
ingrained ideas of loose and reckless female sexualities. In this light, many women in casual sexual encounters avoid requesting condoms for fear of losing
a respectable self-image. Finally, we have seen how
condoms create mistrust, or “put a monkey wrench
in the relationship” as one of the focus group participants put it. In other words, putting on or requesting
condoms without prior and elaborate verbal negotiation can easily breach legitimate images of fidelity
and trust in a monogamous relationship (El-Bassel
et al., 2001; El-Bassel, Gilbert, Rajah, Foleno, &
Frye, 2000; Gilbert et al., 2000; Sobo, 1993, 1995). A
husband putting on a condom may send the message
that he has cheated or that he is suspicious of his wife.
In turn, a woman requesting a condom can signify to
her fiancé that she suspects infidelity.
In short, among these men in MMTPs, the protective act of putting on, or being requested to put on,
a condom in the context of heterosexual relationships
may disrupt cultural scripts and social performances
of what it means to be a man (because condoms can
threaten masculinity), what it means to be a proper
woman (because condoms can indicate promiscuity), or what it means to be in a committed relationship (because condoms can destabilize trust and
monogamy). From a sociological standpoint, it can
be argued that (avoiding) risking the institutions of
Accounting for HIV Risk Among Men on Methadone
gender (masculinity or femininity) and/or monogamy
(marriage) in the sexual context of self-presentations
is more motivationally relevant to these men than
risking their lives to HIV infection. For the phenomenological self, to avoid risking the institutions
of gender or monogamy is felt as the need to save
face in the “here and now,” a motivational process
that should always be understood as semiconscious
rather than strictly discursive.
As mentioned before, risky accounts—whether
nihilistic, fatalistic, hedonistic, and normative—are
rarely found in isolation but in multiple and sequential narrative stories that work in tandem. Thus, for
example, being “dope sick” or on a “drug high” never
occurs in a vacuum but in contexts where individuals still need to present their selves in gendered
and/or faithful ways. In contrast to more rigid culturalist models of HIV risk-taking indicated in the
Introduction, we found that in any particular HIV
risky episode more than one type of cultural narrative and account may be used to guide and make
sense of behaviors. In fact, complex constellations of
account-making that draw on a number of different
cultural narratives are typical among these men on
methadone. Thus, for example, an individual can account in general for an HIV “unsafe” night of passion with his girlfriend in multiple and very different
ways: He can tell himself that he was drunk (hedonistic account) and alcohol makes one do wild things
(hedonistic narrative); that he was not only drunk but
also very tired of living as a junkie (nihilistic account)
and when one is a junkie one is self-destructive about
things (nihilistic narrative); that with all his past and
present recklessness, if he is not already infected (fatalistic account) he will never be (fatalistic narrative);
he can also tell himself that he was not too much
into sex that night (normative account) and losing
his erection further by putting on a condom would
have been pretty embarrassing as a man (normative
narrative); that it would have been not only embarrassing but also sexually unsatisfying to his girlfriend
(normative account) who expects to be satisfied (normative narrative); or that his girlfriend made him so
angry when she refused to have a certain kind of sex
that he penetrated her anyway (normative account)
because men should always be in control of sex
(normative narrative).
In this connection, an individual can feel drunk,
but tired of living, can believe he is invulnerable,
have potency problems, and feel he is losing control of the sexual act all in one same sexual episode
and at different junctures. Our focus group anal-
623
ysis indicates that most ex-post facto accounts reflected in these men’s narratives and stories were
delivered in various and rich “performative” combinations. Further qualitative studies to elicit complex in-depth narratives are needed to explore which
risky account-making combinations are more prevalent and relevant than others according to diverse
circumstances and sex partners. From the present
study’s findings, for example, it appeared that fatalistic accounts are less prevalent than others. Moreover,
further research may disentangle the effects of class
and ethnicity, drug type, and life course on the diversity of nihilistic, fatalistic, hedonistic, and normative
account-making of men on methadone.
ACKNOWLEDGMENTS
This research was supported by Grant
#DA12335 from the National Institute on Drug
Abuse. The authors express their appreciation to
John Key and Dr. Dexter Voisin, who assisted in
the implementation and facilitation of the focus
groups. The authors are also thankful to the staff
and patients at the Beth Israel Medical Center, who
made this study possible.
REFERENCES
Amaro, H. (1995). Love, sex, and power: Considering women’s
realities in HIV prevention. American Psychologist, 50, 437–
447.
American Medical Association. (1992). Violence against women:
Relevance for medical practitioners. JAMA, 267, 3184–3189.
Auer, P., & Di Luzio, A. (Eds.) (1992). The contextualization of
language. Philadelphia, PA: John Benjamins.
Bellaby, P. (1990). To risk or not to risk? Uses and limitations of
Mary Douglas on risk acceptability for understanding health
and safety at work and road accidents. Sociological Review,
38, 465–483.
Bennett, L., & Larson, M. (1994). Barriers to cooperation between
domestic violence and substance abuse programs. Families in
Society, 75, 277–286.
Bloor, M. (1985). Observations of abortive illness behavior. Urban
Life, 14, 300–316.
Bloor, M. (1995). The sociology of HIV transmission. London, UK:
Sage.
Bloor, M., McKeganey, N., Finlay, A., & Barnard, M. (1992). The
inappropriateness of psycho-social models of risk behavior
to understanding HIV-related risk behavior among Glasgow
male prostitutes. AIDS Care, 4, 131–137.
Brown, B. S., & Beschner, G. M. (1993). Handbook on risk of
AIDS: Injection drug users and sexual partners. Westport, CT:
Greenwood.
Browne, A. (1993). Violence against women by male partners:
Prevalence, outcomes, and policy implications. American
Psychologist, 48, 1077–1087.
Butler, J. (1990). Gender trouble: Feminism and the subversion of
identity. New York, NY: Routledge.
624
Centers for Disease Control and Prevention (CDC). (2003a).
HIV/AIDS surveillance report, 15. Atlanta, GA: Centers
for Disease Control. Retrieved from http://www.cdc.gov/hiv/
stats/2003SurveillanceReport.pdf
Centers for Disease Control and Prevention (CDC). (2003b).
HIV/AIDS among Women. Atlanta, GA: Centers for
Disease Control. Retrieved from http://www.cdc.gov/ hiv/
pubs/facts/women.pdf
Connell, R. W. (1995). Masculinities. Berkeley, CA: University of
California Press.
Davis, M. (1983). Smut: Erotic reality/obscene ideology. Chicago,
IL: University of Chicago Press.
Dingwall, R. (1976). Aspects of illness. Oxford, UK: Martin
Robertson.
Douglas, M. (1985). Risk acceptability according to the social sciences. New York, NY: Sage.
Douglas, M. (1992). Risk and blame: Essays in cultural theory. New
York: Routledge.
Douglas, M., & Calvez, M. (1990). The self as risk taker: A cultural
theory of contagion in relation to AIDS. Sociological Review,
38, 445–464.
Edwards, G. (1994). Alcohol policy and the public good. Oxford,
UK: Oxford University Press.
El-Bassel, N., Fontdevila, J., Gilbert, L., Voisin, D., Richman, P.,
& Pitchell, P. (2001). HIV risk of men in methadone treatment programs who abuse their intimate partners: A forgotten issue. Journal of Substance Abuse, 13, 29–43.
El-Bassel, N., Gilbert, L., Rajah, V., Foleno, A., & Frye, V. (2000).
Fear and violence: Raising the HIV stakes. AIDS Education
and Prevention, 72, 379–401.
Elster, J. (1999). Strong feelings: Emotion, addiction, and human
behavior. Cambridge, MA: MIT Press.
Emerson, R. M., Fretz, R. I., & Shaw, L. L. (1995). Writing ethnographic fieldnotes. Chicago, IL: The University of Chicago
Press.
Garfinkel, H. (1967). Studies in ethnomethodology. Engelwood
Cliffs, NJ: Prentice-Hall.
Gilbert, L., El-Bassel, N., Rajah, V., Foleno, A., Fontdevila, J.,
Frye, V., & Richman, B. (2000). The converging epidemics
of mood-altering-drug Use, HIV, HCV, and partner violence:
A conundrum for methadone maintenance treatment. Mount
Sinai Journal of Medicine, 67, 452–464.
Gilbert, L., El-Bassel, N., Schilling, R. F., Catan, V., & Wada, T.
(1996). Partner abuse and sexual risk behavior among women
on methadone. Presented at The American Public Health Association 124th Annual Meeting and Exposition. New York,
NY.
Gilmore, D. D. (1995). Manhood in the making: Cultural concepts
of masculinity. New Haven, CT: Yale University Press.
Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded
theory: Strategies for qualitative research. Chicago, IL:
Aldine.
Goffman, E. (1955). On face-work: An analysis of ritual elements in social interaction. In B. Blount (Ed.), Language,
culture, and society (pp. 222–247). Prospect Heights, IL:
Waveland.
Goldstein, N., & Manlowe, J. (1997). The gender politics of
HIV/AIDS in women: Perspectives on the pandemic in the
United States. New York: New York University Press.
Fontdevila, El-Bassel, and Gilbert
Guinan, M. E., & Hardy, A. (1987). Epidemiology of AIDS in
women in the United States: 1981 through 1986. JAMA, 257,
2039–2042.
Johnson, B. (1987). The environmentalist movement and
grid/group analysis: A modest critique. In B. Johnson & V.
Corvello (Eds.), The social and cultural construction of risk.
Dordrecht, The Netherlands: Reidel.
Kantor, G. K., & Straus, M. A. (1987). The drunken bum theory
of wife beating. Social Problems, 34, 213–229.
Karon, J., Fleming, P., Steketee, R., & De Cock, K. (2001). HIV in
the United States at the turn of the century: An epidemic in
transition. American Journal of Public Health, 91, 1060–1068.
Kippax, S., Crawford, J., & Waldby, C. (1994). Heterosexuality,
masculinity, and HIV. AIDS, 8, 315–323.
Lucy, J. A. (Ed.) (1993). Reflexive Language: Reported Speech
and Metapragmatics. Cambridge, MA: Cambridge University
Press.
McKeganey, N., & Barnard, M. (1992). AIDS, drugs and sexual
risk: Lives in the balance. Philadelphia, PA: Open University
Press.
Monagham, L. F. (2002). Opportunity, pleasure, and risk: An
ethnography of urban male heterosexualities. Journal of Contemporary Ethnography, 31, 440–477.
Morgan, D., & Krueger, A. (1997). The Focus Group Kit (Vols.
1–6). Thousand Oaks, CA: Sage.
Morrill, A., & Ickovics, J. (1996). Surviving abuse and HIV-risk:
How women’s experience of abuse shapes their heterosexual
risk for HIV [Tu.D. 134]. Presented at The XI International
Conference on AIDS. Vancouver, Canada (July).
Orbuch, T. L. (1997). People’s accounts count: The sociology of
accounts. Annual Review of Sociology, 23, 455–478.
Orford, J. (1985). Excessive appetites: A psychological view of the
addictions. Chichester, UK: Wiley.
Parker, R. N., & Auerhahn, K. (1998). Alcohol, drugs, and violence. Annual Review of Sociology, 24, 291–311.
Plichta, S., & Abraham, C. (1996). Violence and gynecologic
health in women younger than 50 years old. American Journal
of Obstetrics and Gynecology, 174, 903–907.
Schutz, A. (1970). Reflections on the problem of relevance. New
Haven, CT: Yale University Press.
Scott, M. B., & Lyman, S. M. (1968). Accounts. American Sociological Review, 33, 46–62.
Sobo, E. J. (1993). Inner-city women and AIDS: The psycho-social
benefits of unsafe sex. Culture, Medicine, and Psychiatry, 17,
455–485.
Sobo, E. J. (1995). Choosing unsafe sex: AIDS-risk denial among
disadvantaged women. Philadelphia, PA: University of Pennsylvania Press.
Straus, M., Hamby, S., Boney-McCoy, S., & Sugarman, D. (1996).
The Revised Conflict Tactics Scales (CTS2): Development
and preliminary psychometric data. Journal of Family Issues,
17, 283–316.
Wingood, G., & DiClemente, R. (1997). The effects of an abusive
primary partner on the condom use and sexual negotiation
practices of African-American women. American Journal of
Public Health, 87, 1016–1018.
Zierler, S., & Krieger, N. (1997). Reframing women’s risk: Social inequalities and HIV infection. Annual Review of Public
Health, 18, 401–436.