“Risks Both Known and Unknown”

ldquoRisks Both Known and UnknownrdquoA Qualitative Method to Assess the Role

of Situation in HIVSTD Risk and Prevention

William N Elwood PhD

Center for Public Health and Evaluation Research Inc

Kathryn Greene PhD

Rutgers University

ABSTRACT The idea of situation has gained increased attention inHIVSTD prevention research and practice In the context of preventionsituation does not simply connote setting or place but also incorporatesmeanings people attached to the physical setting and how the complexinterrelation of setting meaning and behaviors influences decisions re-garding sexual behaviors and prevention measures Kenneth Burkersquospentadic analysis provides a means to illuminate how situation influ-ences decisions regarding sexual behaviors and risk taking This manu-script describes the pentadic method its application to situation andsexual risk behaviors and its utility through content analysis of tran-scribed interviews (or texts) with men who patronize bathhouses bath-

William N Elwood is executive director of the Center for Public Health and Evalu-ation Research Inc Key West FL Kathryn Greene is Associate Professor in the De-partment of Communication Rutgers University New Brunswick NJ Support forsome data collection was provided by a grant from the Community Research BranchNational Institute on Drug Abuse R C Freeman principal investigator The opinionsherein however are expressly those of the authors Authors would also like to thankStacey Connaughton and an anonymous reviewer for their feedback on this manu-script Correspondence may be addressed Dr William Elwood 3355 Donald AvenueKey West FL 33040-4488 (E-mail wnelwoodearthlinknet)

Journal of Homosexuality Vol 50(1) 2005Available online at httpwwwhaworthpresscomwebJH

copy 2005 by The Haworth Press Inc All rights reserveddoi101300J082v50n01_07 135

house staff members and release forms from bathhouse establishmentsin three geographic areas In this case the analysis reveals that bath-house patrons and policies perceive bathhouses as situations that priv-ilege expedient sexual release rather than individuals and over howthose releases occur This predominant perspective impedes but doesnot preclude risk reduction The authors provide recommendationsfor promoting condom use for anal sex in the bathhouse setting as wellas for the utility of pentadic analysis in related research [Article copiesavailable for a fee from The Haworth Document Delivery Service1-800-HAWORTH E-mail address ltdocdeliveryhaworthpresscomgtWebsite lthttpwwwHaworthPresscomgt copy 2005 by The Haworth Press IncAll rights reserved]

KEYWORDS Bathhouses condom use HIVSTD MSM situationaltheory dramatism pentadic analysis Kenneth Burke

Bathhouses have been the object of discussions regarding HIV andAIDS since the advent of the epidemic Suspected at first as a ldquocauserdquo ofHIV infection bathhouses were closed by law in many United Statescities Like any tangible setting bathhouses cannot compel patrons toengage in sexual risk behaviors however some public health researchhas found that men who have sex with men (MSM) who were bathhousepatrons were more likely to be infected with sexually transmitted dis-eases than MSM who did not patronize bathhouses (Binson et al 2001Izazola-Licea et al 1991 Merino Judson Bennett amp Schaffnit 1979Morris Zavisca amp Dean 1995 Newell et al 1985) Despite this well-publicized finding MSM continue to engage in sexual risk behaviors inbathhouses (Binson et al 2001 Elwood Greene amp Carter 2003Elwood amp Williams 1998 1999 Goode 2001)

Some scholars argue that bathhouses have been settings for sexualencounters since their inception (eg Beacuterubeacute 1996) Recent archeolog-ical findings in Pompeii suggest that the ancient Romans commonlyconsidered bathhouses to be a setting for sex among patrons (ldquoItalyrdquo2001 ldquoUnisex bathhouserdquo 2001) Nevertheless one might say that lat-ter-day MSM who attend bathhouses and other sexual environments(eg sex clubs tearooms cottages and adult bookstores) are simply in-dividuals who take risks in terms of public exposure and HIVSTD in-fection Binson and colleagues (2001) examined data from a telephonesurvey of 2881 MSM in four US cities and found that men who used

136 JOURNAL OF HOMOSEXUALITY

party drugs and had unprotected anal intercourse (UAI) with non-pri-mary partners were more likely to patronize sex venues than men whodid not report such behaviors Furthermore these researchers found thatmen who attended both bathhouses and public cruising areas were morelikely to report risky sexual behaviors than men who frequented onlypublic cruising areas or who attended neither setting Other researchhowever has found that some bathhouse patrons avoid engaging in sex-ual risk behaviors (eg UAI) because these men perceived bathhousesas settings where their sex partners were more likely to be infected withHIV and other STDs (Elwood amp Williams 1999) Clearly not to under-stand the significance MSM place on the settings in which they have sexis to risk losing opportunities to understand risky and protective behav-iors and to use those understandings in future public health interven-tions

Researchers have explored the notion that some MSM attend sexualenvironments including bathhouses to be in situations where they canfulfill desires to escape cognitive awareness of daily stressors includingHIVAIDS and its prevention According to McKirnan Ostrow andHope (1996) ldquoSettings such as gay bars or bathhouses sexually-ori-ented events or a particular partner may both present opportunities forsexual risk and cognitively release the personrdquo from safer sexual norms(p 658 see also Elwood amp Williams 1998 Kelaher Ross RohrsheimDrury amp Clarkson 1994 Kippax et al 1998 Ostrow amp McKirnan1997) Similarly Levine (1998) posited that gay sexual scripts ac-quired during youth andor the coming out process are those ldquourginghigh-frequency recreational sex and discouraging emotional affilia-tionsrdquo (p 23) In other words MSM may attend bathhouses to pursue asexual escape opportunity in which they may be predisposed to have sexaccording to traditional gay sexual scripts rather than to think morerationallyndashand about HIVSTD preventionndashbefore engaging in sexualepisodes

SITUATIONAL THEORYSETTINGS BEHAVIORS AND SIGNIFICANCE

Individual motives psychoactive substance use and other factorsthat exist within bathhouse settings clearly influence risk behaviors andrisk-avoidance behaviors in bathhouses Much attention has beenplaced on bathhouses over the past two decades however few conclu-sions have been reached as to the nexus of the bathhouse sexual situa-

William N Elwood and Kathryn Greene 137

tion and MSMrsquos sexual risk behaviors Situational theory posits thatpeople behave in response to their physical settings the significancethey attach to those settings and their responses to othersrsquo behaviorswithin their proximity (Cantor 1981 Elwood 1999 Magnusson1981) To understand such a complex phenomenon we must turn to thediscourse about sexual behaviors in specific settings because peoplersquosrecollections of behaviors within given situations provide the ways eachindividual perceived that setting and how specific behaviors reflectedthose situational perceptions (Burke 1984 p 35)

DRAMATISMAN APPROACH TO UNDERSTAND SITUATIONS

AND BEHAVIORS

Perhaps best described as a philosophical sociologist or even the ac-cidental founder of cultural studies (McLemee 2001 p 27) Burke(1941) first gained attention in this regard upon publication of his cri-tique of Mein Kampf Burke asserted his theory of human behaviordramatism as a theoretical and ontological approach for understandinghuman behavior Simply put ldquoThings move persons actrdquo (Burke 1967p 331) and language is ldquoa mode of conductrdquo another human behaviorthat acts upon and within the world (Burke 1955 p 259) The languageone uses then delineates onersquos view of the world what behaviors aredeemed appropriate for oneself and what treatment is suitable for oth-ers Burke defined his lifelong project as ldquoto formulate the basic strata-gems by which people employ in endless variations and consciously orunconsciously for the outwitting or cajoling of one anotherrdquo (Burke1969 p xvii) Scholars have argued over dramatism as an ontologicalor epistemological approach since Burkersquos emergence in the 1920s the21st century has wrought increasing regard for dramatism asontological and literal (see Crable 2000a 2000b Hawhee 1999McLemee 2001)

Dramatism Language as Symbolic Behavior

Similar to situational theory Burke posits that situations cannot beunderstood without exploring peoplersquos behavior and their individualmeanings which he calls motives In Burkersquos words ldquoMotives areshorthand terms for situationsrdquo (1969 p 29) Parenthetically fans of re-


cording artist Harry Chapin can find Burkersquos lyrics and music on hisgrandsonrsquos albums (Coan 1987)

For Burke language is symbolic constitutive behavior because lan-guage constructs the situation that facilitates how one should considerthe meanings attributed to places things people and their behavior(Burke 1969 p 84 1966 p 359-360)ndashor as he stated more simplyldquowhat people are doing and why they are doing itrdquo (Burke 1969 p xv)To define or delineate an entity is to constitute it within a context set-ting or situation For example

To call a man a friend or a brother is to proclaim him consubstantialwith oneself onersquos values or purposes To call a man a bastard isto attack him by attacking his whole line his lsquoauthorshiprsquo hislsquoprinciplersquo or lsquomotiversquo (as expressed in terms of the familial)(Burke 1969 p 57)

Burke posits that our words reveal attitudes that inform our observa-tions and behaviors ldquoOur introspective words for motives are roughshorthand descriptions for certain typical patterns of discrepant andconflicting stimulirdquo (1984 p 29) As motives simply do not jump intothe consciousness of individuals who account for their behavior or tothe scientists who examine them Burke provides instruction forinvestigation

We take it for granted that insofar as men cannot themselves cre-ate the universe there must remain something enigmatic about theproblem of motives and that this underlying enigma will manifestitself in inevitable ambiguities and inconsistencies among theterms for motives Accordingly what we want is not terms thatavoid ambiguity but terms that clearly reveal the strategic spots atwhich ambiguities necessarily arise (Burke 1969 p xviii)

Burkersquos Pentad Five Components to Dramatism

According to Burke ldquoDramatism is a set of five terms that delineatethe necessary requirements for actionrdquo (1969 p 3) Burkersquos method toanalyze human discourse that illuminates their motives and physical be-haviors is the pentad According to Burke the pentad allows us to seeldquoWhat is involved when we say what people are doing and why they aredoing itrdquo (1984 p xv) According to Edwards (1998) Burkersquos ldquouseful


analytical devicerdquo is ldquothe tool of inquiry [that] unpacks the elements of asituation so that their dynamics can be understoodrdquo (p 168)

The pentad consists of five interrelated components that empower ananalyst to determine an individualrsquos motivesndashthat is how one perceivedonersquos self in a specific setting and how those perceptions shaped onersquosactions More specifically ldquoFor there to be an act there must be anagent Similarly there must be a scene in which the agent acts To act ina scene the agent must employ some means or agency And there can-not be an act in the full sense of the term unless there is a purposerdquo(Burke 1967 p 332 see also Burke 1968 p 446) In particular

You must have some word that names the act (names what tookplace in thought or deed) and another that names the scene (thebackground of the act the situation in which it occurred) also youmust indicate what kind of person (agent) performed the act whatmeans or instruments he used (agency) and the purpose Men mayviolently disagree about the purposes behind a given act or aboutthe character of the person who did it or how he did it or in whatkind of situation he acted or they even may insist upon totally dif-ferent words to name the act itself Be that as it may any completestatement about motives will offer some kind of answers to thesefive questions what was done (act) when or where it was done(scene) who did it (agent) how he did it (agency) and why (pur-pose) (Burke 1969 p xv)

An analyst using dramatism looks for terms that correspond to thepentadic components and how those terms correspond to one anotherAll sets of relationships among the components are possible the pre-ponderance of specific pentadic relationships defines or illumines hu-man motives related to specific behaviors For example if one listenedto a colleaguersquos anecdote about a trip to an annual professional meetingand heard an abundance of passive language one likely would find apredominance of act-agent ratios or an approach to life in which ldquoev-erything happensrdquo to your colleague and perhaps an innate belief thatyour colleague believes that she has scant power regarding careerchoices Thus it is important not only what elements are found but theirrelative frequency and co-occurrence

Related pentadic applications The pentad has been used to explain avariety of human attitudes and behaviors including for example politi-cal opinion (eg Brummett 1982 Edwards 1998 Ling 1970) and eu-thanasia (Kenny 2001) Among the applications most germane to this


present study of MSM and bathhouses is Solomonrsquos (1985) analysis ofmedical reports from the Tuskegee Syphilis Project (for a description ofthe Tuskegee project see Jones 1981) Solomon found that the reportsrsquodetached language typical of medical and public health research de-picted patients as scene and agency Specifically the reports generallyportrayed syphilis (agent) as acting in the scene of the patient or that pa-tients served as the agency for the purpose of increasing knowledge ofthe effects of untreated syphilis in human beings Such symbolic actionaccording to Solomon tacitly perpetuated Jim Crow attitudes and prac-tices against African-Americans and also perpetuated a framework of(Burkean) motives that empowered the Tuskegee project to continue fordecades

Brummett (1979) examined the motives associated with argumentspromoting and dissuading gay rights ordinances According toBrummett the motives that emanate from the pro-gay rights argumentconcentrate on agent-act ratios in other words gay people have roman-tic feelings and sexual relationships with people of their own sex be-cause of innate characteristics Consequently proponents assert thatcitizens should consider an agentrsquos right to be gay (agent-act) sepa-rately from opinions regarding gay peoplersquos private sexual behaviors(Brummet 1979 p 253) In contrast opponents base their argumentson act-agent ratios (Brummet 1979 pp 255-258)ndashthat people are gaybased on their sexual behaviors which are forbidden in the OldTestament (Brummet 1979 pp 256-257)

Summary

In the present study to attend MSMrsquos descriptions of their bathhousesexual encounters is to begin to understand why MSM profess the im-portance and practice of safer sex behaviors yet engage in sexual riskbehaviors in bathhouses Pentadic analysis to MSMrsquos descriptions oftheir sexual behaviors in bathhouse settings illuminates their under-standings of the bathhouse situation and how this specific situationinfluences their choices and behaviors

METHODS

In-depth semi-structured interviews were conducted in 1996 and2001 with men who reported recently having had sex with another manin a bathhouse Forty-one of these men were interviewed in Houston in


1996 These interviews were extended using the same interview guidewith 40 participants in Key West Florida and 20 men in and aroundNew York New York The Houston sample consisted of men mostly intheir 30s although ages ranged from 18 to 58 these men were predomi-nantly whiteAnglo although three African-American and seven Latinomen were interviewed The Key West sample consisted of men mostlyin their 30s although ages ranged from 22 to 89 There were 20whiteAnglo 10 African-American and 10 Latino participants in KeyWest The New York area sample consisted of men mostly in their 30sages ranged from 19 to 51 There were seven whiteAnglo five African-American six Latino and two Asian-American men For the entiresample most of the men were employed often at managerial positionsFour men reported being in committed romantic relationships andseventeen reported being infected with HIV

Candidates for the study were recruited through advertisements in lo-cal newspapers and by referral from men already participating in thestudy (see Patton 1990 Watters amp Biernacki 1989) Advertisementand participant referrals asked men to call one of the authors to deter-mine study eligibility During the initial phone conversation partici-pants were screened to meet the following criteria to be at least 18 yearsof age to report having had sex with another male in a bathhouse withinthe last six months and to give verbal consent to be interviewed Forparticipants who met the criteria the phone interview was concludedwith an appointment for an interview at a later date

Data were collected using an interview guide that included questionsconcerning sexual behaviors and history sexual behaviors in bath-houses attitudes toward HIV STDs and prevention methods includingcondoms gay mores sociodemographics and life history Although thequestions served as a prompt and guide for the interviewer participantswere encouraged to elaborate on topics that appeared to contain infor-mation relevant to the study Interviews generally lasted two hours(range 45 minutes to 3 hours) were (audio) tape recorded and weretranscribed verbatim into text files In turn text files were content codedusing objective analytical codes Included were codes for the researchsubjectsrsquo perceptions of bathhouses attitudes and beliefs toward HIVSTDs and condom use and perceived community norms regarding sexand condom use Other predetermined codes included the five terms as-sociated with Burkersquos pentad (eg act agent scene) as well as pentadicratios (eg scene-act act-purpose)

One of the authors and a research assistant coded all interviews eachcoded an additional 10 in common with reliability of 95 across


codes These instances were analyzed and kappas were calculated forpresenceabsence and positivenegative and they ranged from 92 to 97(mean = 95) Disagreements were discussed between coders until 100percent agreement was reached Data that best illustrate analytical pat-terns were excerpted for presentation in the text below

We also conducted a content analysis of 10 bathhouse membershipapplications and release forms from establishments in the metropolitanareas of New York New York Houston Texas Miami Florida andKey West Florida Coding and analysis procedures closely followedthose outlined in the previous paragraphs the intercoder reliabilitiesremained the same

RESULTS

This project relies on three sources of data to understand the com-plexities of MSMrsquos bathhouse behavior The first section of results ex-plores pentadic themes that emerged in interviews with bathhousepatrons The second section analyzes bathhouse release forms and in-cludes interviews with bathhouse staff and patrons The third and finalsection bathhouse practices focuses on reported behaviors By utiliz-ing this triangulation for data we gain a more comprehensive picture ofrisk behavior and perceptions in this setting

Pentadic Themes Represented in Interviews with Bathhouse Patrons

We found four dominant ratios in the discourse of the men that we in-terviewed scene-purpose scene-act scene-agent and agency-act Par-ticipantsrsquo descriptions were resoundingly clear when they recounted theinfluence of scene (bathhouse) on their purpose (orgasmrelease) act(UAI) and self (agent) Their descriptions of protected sex demonstratethat condom use requires multiple and complex interactions in a situa-tion where basic and forthright interactions are commonplace

Scene-purpose The first ratio that emerged from the interviews wasscene-purpose During the interviews we conducted men reported thatthey patronized bathhouses (scene) because the setting virtually guaran-teed that they would achieve their goal of orgasm (purpose) Accordingto one man ldquoI know that I can go there and get what I want whereasIrsquove gone to the bar and gone home alonerdquo In the words of another pa-tron ldquoI pay I get in I get off and I go homerdquo According to a New Yorkwhite gay man in his 30s ldquoItrsquos worth the [admission] fee Therersquos no


hassle that way you get what you wantrdquo Another New Yorker an Ital-ian man in his 40s echoed this sentiment with greater detail ldquoI got tiredof paying for dinner or all those drinks [in a bar] Eventually I wanted asure score In the long run itrsquos much cheaper and predictablerdquo Accord-ing to a Key West man ldquoI go there because I just want someone to getoff with the way that I wantrdquo Thus participants clearly articulated thepurpose (sexual release) of the bathhouse setting This describedpurpose is accomplished through acts described next

Scene-act Perhaps our favorite quotation from this data set exempli-fies this ratio in reverse ldquoHey you donrsquot go to a bathhouse [scene] tohave a conversation [act] about Bosniardquo According to a New Yorkman ldquoSome ads and articles talk about bathhouses as spas or gyms Idonrsquot know anyone who thinks that way Everyone knows that bath-houses exist only so guys can get together and fuckrdquo A New Jersey manstated ldquoI donrsquot want to talk I just go and have sex lots of it any way Iwantrdquo A Houston man who juggles many responsibilities said ldquoIrsquom avery busy person I donrsquot have time to date or find a boyfriend But I tellmyself all week long that on Friday Irsquom going to the bathhouse Be-cause when Irsquom in the bathhouse I just fuck fuck fuckrdquo Thus thebathhouse setting is linked in participantsrsquo minds with the act of sexualrelease

Scene-agent The innate connection of bathhouses as situations forsexual release appears to explain the thought processes or lack thereofrelated to the ldquoheat of the momentrdquo A 25-year-old Houston Latino pa-tron told a story that demonstrates how perceptions of the bathhouse set-ting preclude condom use

There was this big Black man in the maze A real man huge cockbulging muscles everywhere you know I just had to have him soI backed right up on him It felt so good I thought we should haveused a condom while he was fucking me but I didnrsquot want to stopor he wouldnrsquot be there later

In the words of another participant who boasted of his ample endow-ment ldquoHey their eyes are on the prize Once they see what I have to of-fer they just get down to it They donrsquot think about condomsrdquo This ldquotopmanrdquo description demonstrates that some bathhouse patrons recognizethe influence of this situation on receptive partnersrsquo attitudes and behav-iors and rely on the complex setting to assure them of unprotected analsex


Agency-purpose Sex with condoms is more complex and involvesother acts aside from sexndashspecifically negotiation between the sex part-ners for condom use According to a New York bathhouse patron ldquoIf Itop him I donrsquot really want to use a condom but if he asks I would Get-ting asked doesnrsquot happen very often maybe once or twice in threeyearsrdquo A 25-year-old Houston man repeated this perception of con-doms ldquoIf theyrsquore there and convenient and if I have them Irsquoll probablyuse them If I donrsquot have one itrsquos not used probably unless they requestitrdquo Patrons who reported being penetrated confirmed this pattern As a38-year-old Key West man described ldquoIf you ask them to put on a con-dom most will Irsquove had maybe one who refused to wear it so we justdidnrsquot have sexrdquo Some men are vigilant about condom use and have de-veloped that reputation among their peers ldquoI know a man with HIVwho goes here [bathhouse] and he always uses condoms has them withhim [Laughs] One time I even borrowed a condom from him Hersquosvery clear and that puts some people offrdquo Both insertive and receptiveMSM generally link condom use to a specific request a request mostoften initiated by the receptive partner

Summary Our examination of bathhouse patronsrsquo discourse findsthat men ascribe specific attributes and functions to bathhouses Theyperceive bathhouses as commercial establishments that provide themwith guaranteed orgasms with other men for the price of entry Conse-quently the physical setting of the bathhouse is filled with patrons whoconsciously or impulsively are determined to achieve orgasms withothers Pentadically speaking this single-mindedness informs menrsquosperceptions of the scene a setting where men ldquohave sex lots of it anyway I wantrdquo As we stated previously three of four main pentadic ratiosprivilege scene The fourth ratio agency-act that appeared in our par-ticipantsrsquo discourse demonstrates that the sexually charged scene pre-cludes the agency of condom use without the addition of condomnegotiationndashan act not included in menrsquos perception of the bathhousesituation In addition to the data from our bathhouse participants we ex-amined release forms and policies and interviewed bathhouse ownersmanagers and employees

Bathhouse Policies

We examined the release forms from bathhouses in Houston KeyWest Miami and New YorkNew Jersey and found five themes thatemerged from the documents


1 There are ldquorisks both known and unknownrdquo in all human en-counters

2 Patron agrees to hold establishment harmless for injury or ill-ness contracted on premises through own behavior

3 Patron provides personal assurance of patronrsquos good health4 Patron recognizes that HIV and other STDs exist5 Patron agrees to behave ldquoin responsible mannerrdquo

Clearly there are legal aspects to these documents designed to pro-tect businesses from legal action and financial loss (scene-purpose) Forexample one Florida establishmentrsquos release form has patrons ac-knowledge that there are ldquorisks both known and unknownrdquo in all life ex-periences Given the businessrsquos gay market and its existence to sell timein a space dedicated to menrsquos sexual encounters this clause presumablyprotects the owners from liability for any infection or injury to a patronon site (affirmed by several managers we interviewed) The second(scene-act) and third themes likely are familiar to anyone who hasjoined a health club or gym which presumably protects these establish-ments from lawsuits for injuries sustained through improper weight-lifting clumsiness or insufficiently disinfected shower floors Therelease forms then contain both familiar and unfamiliar language forpatrons

Four of 10 release forms that we reviewed specifically asked patronsto acknowledge the existence of risk for HIV and other STDs None ofthese documents ask patrons to disclose HIV status (positive negativeor untested) nor did the release forms expressly ask these men to ab-stain from sexual risk behaviors on site It is possible that the thirdtheme assuring the establishment that the patron is ldquoin good healthrdquocould be understood to mean that the patron does not have HIVndashal-though this is not expressly stated In fact one man with HIV from NewYork said he had read the form but did not disclose his infection becauseit was not specifically requested Our project found that regardless ofthe intent of the release forms the customers we interviewed paid themlittle attention

Few patrons recalled any verbiage from the documents they signedsome did not recall seeing or signing any forms whatsoever One mansaid ldquoWhat form I never signed anythingrdquo Another man from NewJersey recalled ldquoYeah there was something that first night but who re-membersrdquo (even though the first night he refers to occurred less than 3months previously) This forgetfulness was countermanded by othersrsquorecollections and the frank statement by one New York patron ldquoHell I


donrsquot know what was on it I signed it and didnrsquot even read it I justwanted to get inside and see what it was likerdquo This dearth of recollec-tion suggests that MSM concentrate on the traditional meanings andmotives MSM associate with bathhouses and remain concerned withspecific establishment rules unless presumably staff members inter-vene and enforce rules that contradict menrsquos behaviors

Bathhouse Practices

The described policies within membership documents appear to ab-solve businesses of responsibility to monitor patronsrsquo behavior Patronsapparently perceive these documents as perfunctory paperwork to com-plete before they satisfy their desires The following quotations frompatrons illuminate the idea that MSM patronize bathhouses (scene) sothey can pursue their intense purpose of sexual release with others

For example one New York patron said ldquoI remember when theyused to have the sex police running around making sure that everyonewas using condoms I stopped going for a while but now no one comesaround any morerdquo A Houston man intuitively reflected on thescene-purpose ratio ldquoIrsquove been to San Francisco where they have clubswhere yoursquore not supposed to do more than hand jobs or blow jobsGuys still do what guys want to do The clubs have guys that patrol withflashlights but I never saw them break up anything Whorsquod go if theydid Then theyrsquod go bustrdquo There is a clear link in participantsrsquo mindsbetween enforcement of safer sex practices particularly condom useand interference with their pleasure and thus bathhouse business andpatronage

Bathhouse managers and staff members provided forthright answersto our questions regarding their prevention policies and practices Ac-cording to managers at the establishment whose release form asks pa-trons to acknowledge that there are ldquorisks both known and unknownrdquo inall human situations ldquoWersquore a social club that provides men with an op-portunity to get together with one another We promote safer sex withinthe greater gay community but we canrsquot monitor everyonersquos behaviorall the time Theyrsquore adults and theyrsquore our customers They know whattheyrsquore doingrdquo A New York bathhouse staff member was much moresuccinct saying ldquoThey make choices they know the riskrdquo Neverthe-less this man also described his establishmentrsquos prevention effortsldquoWe have a few signs around People know they should use condomsrdquoA bathhouse assistant manager from Houston said


People are responsible for their own behaviorndasheven gay men al-though yoursquod never know it from how they act in here And whenit comes down to it wersquore a business not a social club or anon-profit community center And when yoursquore a business thecustomer is always right We have condoms available all aroundthe facility and they can always ask an attendant for them but wecanrsquot make them use them

Indeed all facilities that participated in our project made condomsavailable to their patrons Some distributed condoms as a com-mon-sense business expenditure and practice others cooperated withlocal health departments or AIDS service organizations as free condomdistribution sites Regardless of the predominantly implicit health pro-motion effortsndashposters signs and condomsndashbathhouse staff membersreadily acknowledged their patronsrsquo risky behavior

DISCUSSION

Bathhouses are commercial establishments that cater to MSM who paythe price of admission so they can have sex with other men To continuelike any other business bathhouses must cater to their customersrsquo desiresthat are briefly stated to achieve specific sexual goals within a limited timeperiod Although bathhouses themselves constitute settings in which menhave sex with one another these physical sites constitute only part of a sex-ual situation The complete situation includes the physical setting the sig-nificance each man attaches to the setting and to sexual intercourse theirbehavior and their responses to othersrsquo behavior within the setting Themeans that researchers have to determine the complex situation of bath-house sex is to examine MSMrsquos motives (Burke 1984) their descriptionsand attributions of their sexual encounters in bathhouses

The pentad is a method for dissecting texts (interview transcriptsand release forms in this study) through use of five dramatistic ele-ments of act agent scene agency and purpose By examining the ra-tio among the elements it is possible to discern which elements orfeatures humans privilege or mute in a set of texts Our study foundthat men who patronize bathhouses do so because they perceive bath-houses as commercial establishments that ensure sexual release in adesired fashion In Burkersquos terms three-quarters of the main pentadicratios privileged scene over the other four components This findingdemonstrates the utility of pentadic analysis to illuminate the influ-


ence of situation on sexual behaviors or that Burkersquos ideas have rele-vance in the application of situational theory to public healthParticipants did not report that the physical setting of bathhousescompelled them to engage in sexual risk behaviors nevertheless aclosed commercial space with sexually charged men whose ldquoeyes areon the prizerdquo constitutes a situation that facilitates exposure to bodilyfluids that may permit disease transmission

Our examination of MSM who patronize bathhouses in three areas ofthe United States found that they commonly perceive sexual partners in thebathhouse setting as part of their situation rather than partners in their sex-ual acts As our participants stated earlier they attend the bathhouse sceneto fulfill the purpose of sexual acts In general they have no interest in es-tablishing relationships of any kind As one patron told us ldquoI donrsquot evenwant to know his name Letrsquos be blunt I want his bodyrdquo Consequentlythere is a tacit policy in MSM culture that men avoid conversation in bath-house public areas This policy expedites individual attainment of sexualsatisfaction the lack of conversation also preserves confidentiality and thepurpose one attaches to the sex act and the other MSM who constitute thebathhouse situation (see Elwood et al 2003)

Although bathhouse sex is public sex its commodification ironi-cally renders it an individualized experience Patrons avoid conver-sations they also avoid reading the paperwork associated withpurchasing time in the bathhouse setting Our analysis of bathhouserelease forms found that they serve the purpose of protecting busi-nesses from lawsuits associated with injury and perhaps infectionwith HIV and other sexually transmitted diseases These forms havepatrons acknowledge that there are risks involved in all human be-havior and that they the patrons are individually responsible fortheir behavior and the consequences thereof Some release forms ex-pressly mention HIV and other STDs all forms require patrons to be-have in a reasonable manner but the forms do not delineate theagency or reasonableness of the acts to occur in a bathhouse Noforms expressly require their patrons to engage in safer sex andor toavoid sexual risk behaviors Not that this matters much anywayndashourparticipants either had no recall of the release form content or didnot even recall release forms at all In any event our examination ofthis documentation and interviews finds that these forms accomplishtheir presumable goal of minimizing the risk of financial loss from po-tential future lawsuits from bathhouse patrons


CONCLUSIONS

Our research project reinforces recent research which concludes thatMSMrsquos sexual encounters in bathhouses constitute a complex situation(Binson et al 2001 Elwood et al 2003 Elwood amp Williams 19981999) It is hoped that our findings can be used to inform future publichealth interventions with MSM and can lead to future work withMSMrsquos mental and physical health Obviously our qualitative studyhas generated hypotheses and conclusions and cannot be generalized tothe larger population of MSM who patronize bathhouses however thehidden nature of this population (eg Watters 1993 Watters ampBiernacki 1989) may help other researchers and practitioners morethan a similar study conducted with say a sample of undergraduates ata large Midwestern university Our study also provides an example ofBurkersquos pentadic method that other researchers may use with other pop-ulations and on nonsexual topics That aside our project leads us tomake four general conclusions

First no one should expect bathhouses to be anything more thancommercial establishments that sell time in a controlled space that al-lows patrons to have sex with one another Bathhouses are not commu-nity centers They are not health education centers even if they arelicensed as health centers They exist to make profits by satisfying cus-tomers and this is acknowledged by patrons and staff alike Their re-lease forms obliquely and directly acknowledge the possibility that theircustomers may sustain harm while on their premisesndashsome forms comeclose to stating that patrons may become infected with HIV during theirtime on site Bathhouse employees stated their interest in providing op-portunities for men to avoid HIV transmission nevertheless they alsostated a laissez-faire attitude namely that bathhouse patrons areresponsible for their own behaviors

Second sex is a commodity to bathhouse customers at least whilethey have sex in that setting Our participants consistently voiced a capi-talistic approach to bathhouses and sex while on the premises They payadmission fees because they expect sexual satisfaction during the timethey are present Obviously sexual satisfaction differs by each individ-ual including type of sex condom use and whether their means towardorgasm even requires a condom to avoid the chance of HIV transmis-sion Regardless sex is a personal individual act for the patrons we in-terviewed It is about achieving their own orgasms and fulfilling theirown desires albeit in the presence of one or more men Given this ego-centric perspective it is not surprising that the motives surrounding a


lack of condom usendashldquoIrsquoll only wear one if they askrdquondashemerged duringour interviews It did seem clear that participants believed casual bath-house partners rated different treatment than a dating or relationalpartner

Third health education efforts with MSM might seek to establish andencourage the cultural more of speaking about condom use during sex-ual encounters in bathhouses We have demonstrated that manyinsertive men specifically pursued anal intercourse without condomssome receptive men did not request condom use because to do so wouldviolate an established tacit policy of avoiding conversation Publica-tions using the initial data collected for this project found that men fre-quently negotiated condom use in bedrooms and in private bathhousecubiclesndashbut they did not do so in bathhouse public areas (Elwood et al2003 Elwood amp Williams 1999)

According to Vaacutezquez-Pacheco (2000) ldquoBroaching the subject [ofHIV transmission] means we have to take some kind of responsibility Strange that twenty years into the epidemic we as gay men canrsquotseem to negotiate this with each other Itrsquos sort of like being one of twopeople stranded in a life raft and not cooperating with the other personin the boatrdquo (p 25) Bathhouses have found that it is good business tomake free condoms available to their patrons Our public health effortsshould work toward providing patrons with the motivation to negotiatecondom use in bathhouse public spaces with their sexual partners inways that maintain the egocentric nature of bathhouse encounters andto show how this is good personal business

The current bathhouse situation generally precludes condom use be-cause MSM reportedly do not consider the agency or means throughwhich they achieve their purpose of sexual release with anonymous oth-ers What is required of researchers and interventionists is to help themdevelop a consciousness that encourages MSM to include the agency ofcondom use in their sexual acts

REFERENCES

Beacuterubeacute A (1996) The history of gay bathhouses In Dangerous Bedfellows [E GColter W Hoffman E Pendleton A Redick amp D Serlin] (Eds) Policing publicsex Queer politics and the future of AIDS activism (pp 187-220) Boston SouthEnd Press

Binson D Woods W J Pollack L Paul J Stall R amp Catania J A (2001) Differ-ential HIV risk in bathhouses and public cruising areas American Journal of PublicHealth 91 1482-1486


Brummett B (1979) A pentadic analysis of ideologies in two gay rights controversiesCentral States Speech Journal 30 250-261

Brummett B (1982) Burkean transcendence and ultimate terms in rhetoric by andabout James Watt Central States Speech Journal 33 547-556

Burke K (1941) The rhetoric of Hitlerrsquos battle In K Burke The philosophy of liter-ary form (pp 191-220) Berkeley University of California Press

Burke K (1955) Linguistic approaches to problems of education In N B Henry(Ed) Modern philosophies and education (pp 259-303) Chicago University ofChicago Press

Burke K (1966) Language as symbolic action Berkeley University of CaliforniaPress

Burke K (1967) Dramatism In L Thayer (Ed) Communication Concepts and per-spectives (pp 327-360) Washington DC Spartan

Burke K (1968) Dramatism In D L Sills (Ed) International encyclopedia of the so-cial sciences Vol VII (pp 445-452) New York The Macmillan Company and FreePress

Burke K (1969) A grammar of motives Berkeley University of California PressBurke K (1984) Permanence and change Third edition with a new afterword Berke-

ley University of California PressCantor N (1981) Perceptions of situations Situation prototypes and person-situation

prototypes In D Magnusson (Ed) Toward a psychology of situations Aninteractional perspective (pp 229-244) Hillsdale NJ Lawrence Erlbaum Associ-ates

Coan P M (1987) Taxi The Harry Chapin story Port Washington NY AshleyBooks

Crable B (2000a) Burkersquos perspective on perspectives Grounding dramatism in therepresentative anecdote Quarterly Journal of Speech 86 318-333

Crable B (2000b) Defending dramatism as ontological and literal CommunicationQuarterly 48 323-342

Edwards J L (1998) The very model of a modern major (media) candidate ColinPowell and the rhetoric of public opinion Communication Quarterly 46 163-176

Elwood W N (1999) Victories to win Communicating HIVAIDS prevention andtolerance In W N Elwood (Ed) Power in the blood A handbook on AIDS poli-tics and communication (pp 415-421) Mahwah NJ Lawrence Erlbaum Associ-ates

Elwood W N Greene K amp Carter K K (2003) Gentlemen donrsquot speak Commu-nication rules condom use and the Theory of Reasoned Action Journal of AppliedCommunication Research 31

Elwood W N amp Williams M L (1998) Sex drugs and situation Attitudes druguse and sexual risk behaviors among men who frequent bathhouses Journal ofPsychology amp Human Sexuality 10 23-44

Elwood W N amp Williams M L (1999) The politics of silence Communicative rulesand HIV prevention issues in gay male bathhouses In W N Elwood (Ed) Power inthe blood A handbook on AIDS politics and communication (pp 121-132)Mahwah NJ Lawrence Erlbaum Associates


Goode E (2001 August 19) With fears fading more gays spurn old preventive mes-sage The New York Times pp 1 30

Hawhee D (1999) Burke and Nietzsche Quarterly Journal of Speech 85 129-145Italy The heat in Pompeii wasnrsquot just volcano (2001 November 15) The Miami Her-

ald p A13Izazola-Licea J A Valdespino-Gomez J L Gortmaker S L Townsend J Becker

J Palacios-Martinez et al (1991) HIV-1 seropositivity and behavioral and socio-logical risks among homosexual and bisexual men in six Mexican cities Journal ofAcquired Immune Deficiency Syndromes 4 614-622

Jones J H (1981) Bad blood The Tuskegee syphilis experiment New York The FreePress

Kelaher M Ross M W Rohrsheim R Drury M amp Clarkson A (1994) Domi-nant situational determinants of sexual risk behaviour in gay men AIDS 8101-105

Kenny R W (2001) Toward a better death Applying Burkean principles of symbolicaction to interpret family adaptation to Karen Ann Quinlanrsquos coma Health Commu-nication 13 363-385

Kippax S Campbell D Van de Ven P Crawford J Prestage G Knox S et al(1998) Cultures of sexual adventurism as markers of HIV seroconversion A casecontrol study in a cohort of Sydney gay men AIDS Care 10 677-688

Levine M (1998) Gay macho The life and death of the homosexual clone New YorkNew York University Press

Ling D A (1970) A pentadic analysis of Senator Edward Kennedyrsquos address to thepeople of Massachusetts July 25 1969 Central States Speech Journal 21 81-86

Magnusson D (1981) Wanted A psychology of situations In D Magnusson (Ed)Toward a psychology of situations An interactional perspective (pp 9-35)Hillsdale NJ Lawrence Erlbaum Associates

McKirnan D J Ostrow D G amp Hope B (1996) Sex drugs and escape A psycho-logical model of HIV-risk sexual behaviours AIDS Care 8 655-669

McLemee S (2001 April 20) A puzzling figure in literary criticism is suddenly cen-tral Did Kenneth Burke intellectual maverick accidentally create cultural studiesThe Chronicle of Higher Education pp A26-27

Merino H I Judson F N Bennett D amp Schaffnit T R (1979) Screening for gon-orrhea and syphilis in gay bathhouses in Denver and Los Angeles Public HealthReports 94 376-379

Morris M Zavisca J amp Dean L (1995) Social and sexual networks Their role inthe spread of HIVAIDS among young gay men AIDS Education and Prevention7(supl) 24-35

Newell G R Mansell P W A Wilson M B Lynch H K Spitz M R amp HershE M (1985) Risk factor analysis among men referred for possible acquired im-mune deficiency syndrome Preventive Medicine 14 81-91

Ostrow D G amp McKirnan D J (1997) Prevention of substance-related high-risksexual behavior among gay men Critical review of the literature and proposedharm reduction approach Journal of the Gay and Lesbian Medical Association 197-110


Patton M Q (1990) Qualitative evaluation and research methods Newbury ParkCA Sage Publications

Solomon M (1985) The rhetoric of dehumanization An analysis of the medical re-ports of the Tuskegee Syphilis Project Western Journal of Speech Communication49 233-247

Unisex bathhouse unveiled in Pompeii (2001 November 25) The Miami Heraldp G7

Vaacutezquez-Pacheco R (2000 June) A code of silence Gay men dating and disclosureBody Positive pp 22-26

Watters J K (1993) The significance of sampling and understanding hidden popula-tions Drugs and Society 7 13-21

Watters J K amp Biernacki P (1989) Targeted sampling Options for the study of hid-den and elusive populations Social Problems 36 416-430


To request single articles from Haworth visitwwwHaworthPresscomjournalsddsaspYou can ordersingle articles here directly from Haworth or throughRightslink We have over 40000 articles ready forimmediate delivery and you can find articles by titleby author name by keyword and more

reg

house staff members and release forms from bathhouse establishmentsin three geographic areas In this case the analysis reveals that bath-house patrons and policies perceive bathhouses as situations that priv-ilege expedient sexual release rather than individuals and over howthose releases occur This predominant perspective impedes but doesnot preclude risk reduction The authors provide recommendationsfor promoting condom use for anal sex in the bathhouse setting as wellas for the utility of pentadic analysis in related research [Article copiesavailable for a fee from The Haworth Document Delivery Service1-800-HAWORTH E-mail address ltdocdeliveryhaworthpresscomgtWebsite lthttpwwwHaworthPresscomgt copy 2005 by The Haworth Press IncAll rights reserved]

KEYWORDS Bathhouses condom use HIVSTD MSM situationaltheory dramatism pentadic analysis Kenneth Burke

Bathhouses have been the object of discussions regarding HIV andAIDS since the advent of the epidemic Suspected at first as a ldquocauserdquo ofHIV infection bathhouses were closed by law in many United Statescities Like any tangible setting bathhouses cannot compel patrons toengage in sexual risk behaviors however some public health researchhas found that men who have sex with men (MSM) who were bathhousepatrons were more likely to be infected with sexually transmitted dis-eases than MSM who did not patronize bathhouses (Binson et al 2001Izazola-Licea et al 1991 Merino Judson Bennett amp Schaffnit 1979Morris Zavisca amp Dean 1995 Newell et al 1985) Despite this well-publicized finding MSM continue to engage in sexual risk behaviors inbathhouses (Binson et al 2001 Elwood Greene amp Carter 2003Elwood amp Williams 1998 1999 Goode 2001)

Some scholars argue that bathhouses have been settings for sexualencounters since their inception (eg Beacuterubeacute 1996) Recent archeolog-ical findings in Pompeii suggest that the ancient Romans commonlyconsidered bathhouses to be a setting for sex among patrons (ldquoItalyrdquo2001 ldquoUnisex bathhouserdquo 2001) Nevertheless one might say that lat-ter-day MSM who attend bathhouses and other sexual environments(eg sex clubs tearooms cottages and adult bookstores) are simply in-dividuals who take risks in terms of public exposure and HIVSTD in-fection Binson and colleagues (2001) examined data from a telephonesurvey of 2881 MSM in four US cities and found that men who used









AND BEHAVIORS





















Summary


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AND BEHAVIORS





















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AND BEHAVIORS





















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DISCUSSION








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DISCUSSION








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DISCUSSION








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Summary


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DISCUSSION








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RESULTS














Bathhouse Policies











Bathhouse Practices







DISCUSSION








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RESULTS














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DISCUSSION








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Bathhouse Policies











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DISCUSSION








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DISCUSSION








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DISCUSSION








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Bathhouse Practices







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DISCUSSION








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“Risks Both Known and Unknown”

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