Crack, crack house sex, and HIV risk

Archives of Sexual Behavior, Vol. 24, No. 3, 1995
Crack, Crack House Sex, and HIV Risk
James A. Inciardi, Ph.D. 1
Limited attention has been focused on HIV risk behaviors of crack smokers
and their sex partners, yet there is evidence that the crack house and the
crack-using life-style may be playing significant roles in the transmission of
H1V and other sexually transmitted diseases. The purposes of this research
were to study the attributes and patterns of "sex for crack" exchanges,
particularly those that occurred in crack houses, and to assess their potential
impact on the spread of HIK Structured interviews were conducted with 17
men and 35 women in Miami, Florida, who were regular users of crack and
who had exchanged sex for crack (or for money to buy crack) during the past
30 days. In addition, participant observation was conducted in 8 Miami crack
houses. Interview and observational data suggest that individuals who exchange
sex for crack do so with considerable frequency, and through a variety of sexuat
activities. Systematic data indicated that almost a third of the men and 89%
of the women had had 100 or more sex partners during the 30-day period
prior to study recruitment. Not only were sexual activities anonymous, extremely
frequent, varied, uninhibited (orten undertaken in public areas of crack
houses), and with rnultiple partners but, in addition, condoms were not used
during the majority of contacts. Of the 37 subjects who were tested for H I V
and received their test results 31% of the men and 21% of the women were
H I V seropositive.
KEY WORDS: crack; crack houses; HIV; prostitution.
INTRODUCTION
In comparison with injection drug users, only limited attention has
been focused on the HIV risk behaviors of crack smokers and their sex
1Center for Drug and Alcohol Studies, University of Delaware, 77 East Main Street, Newark,
Delaware 19716.
249
0004-0002/95/0600-0249507.50/0© 1995PI¢numPubüshingCorporafion
250
Inciardi
partners. Yet there is evidence to suggest that the crack house plays a significant role in the transmission of HIV and other sexually transmitted diseases.
During the second half of the 1980s, reported rates of sexually transmitted diseases (STDs) increased dramatically, particularly for syphilis. In
the 1-year period from 1986 to 1987, for example, reported syphilis cases
increased by 25% in the United Stares, with rates per 100,000 expanding
for all groups of women as weil as African American and Hispanic men
(Guinan, 1989). In New York City, congenital syphilis increased by more
than 500% between 1986 and 1988 (Schultz et al., 1990). These increases
are not geographically specific, but have been reported in numerous locales.
Accumulating evidence linked these STD increases to the crack epidemic,
in that rates were significantly higher among crack users than nonusers
(Fullilove et al., 1990, Rolfs et al., 1990). Even more important, it appears
that crack use is contributing to the spread of HIV and AIDS. For example,
data from Beile Glade, Florida, reported relationships between the number
of sex partners, condom use, and HIV seropositivity (Trapido et al., 1990).
Among the 50 drug users in this study, only 1 was currently using intravenous drugs. However, 97% were current users of crack, and for the group
as a whole, some 20% had either HIV or AIDS.
There was a time when crack users were not considered to be at particularly high risk for HIV acquisition and transmission. As recently as 1988,
researchers in New York City suggested the adoption of crack smoking, in
lieu of intravenous cocaine use, as a mechanism of AIDS risk reduction
(Des Jarlais and Friedman, 1988). However, recent studies indicate that
when compared with intravenous drug users, crack smokers may be at equal
or greater risk for HIV and other STD infections. In one study of East
Coast prostitutes, rates of HIV seropositivity were higher among the crack
users than among the drug injectors (Sterk, 1988). Similarly, data from a
San Francisco ethnography suggested that women addicts who traded sex
for crack were more likely to spread HIV infection than women who used
heroin or cocaine (Bowser, 1989). It appears that the crack-using life-style
may play a special and perhaps unique role in the transmission of STD.
METHODS
The primary purposes of this research were to develop preliminary
insights into the attributes and pattems of "sex-for-crack" exchanges, particularly those that occurred in crack houses, and to assess the potential
impact of sex-for-crack exchange behaviors on the spread of HIV infection.
Crack, Crack House Sex, and H1V
251
To accomplish these goals, basic "ethnographic" field study techniques were
utilized.
Like other methods in the social and behavioral sciences, ethnography
in its broadest sense involves analytic description of behaviors that characterize cultures and particular sociocultural groups. But unlike other approaches, ethnography also includes description and analysis of the beliefs
that generate and interpret those behaviors (Walters, 1980). As such, ethnography answers the questions: Who are these people, what are they doing, and why are they doing it?
Ethnographers use a variety of approaches to derive their understandings. Typically referred to as "qualitative" research methods, they include such things as participant observation, life histories, and case studies,
as well as structured, semistructured, and open-ended interviews. Most
orten associated with ethnographic methods is "participant observation."
Its underlying premise is that one cannot really know, understand, and describe a different culture or alternative way of living without "stepping into"
it, "living the life" to the extent that it is legally and ethically possible.
Ethnographers refer to this process as "fieldwork," and its success is based
on the development of respect and trust between the researcher and subjects. The ethnographic process, furthermore, usually requires significant
time for fieldwork, systematic data collection, and data analysis, thereby
distinguishing it from short-term investigative reporting.
Like other areas of science, refiability of data is achieved through multiple observations--examinations in alternative settings, interviews with numerous key informants and other relevant people, weighing the credibility
of one subject's views against those of others, and comparing one's findings
with related work.
In this study, data were collected through both systematic interviews
and ethnographic field observations. The systematic interviews were conducted with 17 males and 35 females who were regular users (3 or more
days a week for the past 30 days) of crack and who had exchanged sex for
crack or money to buy craek within the 30-day period prior to study recruitment. These interviews were accomplished through the use of an interview guide that focused on current and past drug use and sexual
behaviors, crack use, crack house activities, HIV risk behaviors, and knowledge and concems about HIV infection. Participation in the study was voluntary, anonymity was guaranteed in that no names were collected, and
informed consent was of a verbal nature. All systematic interviewing was
condueted during the period November 1989 through June 1990. Of the
subjects, 62% (n = 32) were interviewed in a local drug treatment facility,
having been screened for study eligibility within 48 hr of their program
entry. The remaining 38% (n = 20) were interviewed at an AIDS outreach
252
Inciardi
office operated by the University of Miami School of Medicine. These latter
subjects had been recruited from the streets by an indigenous field worker
who accompanied them to the outreach office. All interviews were recorded, and subjects were paid $40 for study participation. The recorded
interviews were transcribed and entered into an ethnographic data base
program. The data reported in Tables I through VII in this paper are drawn
from these systematic interviews.
In addition to the 52 systematic interviews, during the period September 1989 through September 1992, 32 observations in 8 crack houses were
completed by the author. The author had been conducting field studies in
Miami since 1972, and during those years he developed numerous contacts
in the drug-using and drug-dealing communities. It was through a number
of these contacts that safe entry into crack houses was secured. In the majority of crack house visits, furthermore, the author was accompanied by a
local cocaine dealer who vouched for the author's authenticity as a public
health "researcher (see Inciardi et aL, 1993, pp. 147-157). In addition to
these observations, from project initiation through March 1993, the author
conducted unstructured interviews with numerous others who served as key
informants, including 32 crack users (contacted either in crack houses or
on the street), 4 crack and/or cocaine dealers, and 4 police officers familiar
with the greater Miami crack scene. Additional insights were obtained from
numerous contacts with other individuals in the local street subculture. The
data gathered through these observations and unstructured interviews were
in the form of handwritten field notes and are used in this paper to describe
crack houses and the activities that occur in them.
RESULTS
As indicated in Table I, although whites, Hispanics, and Asians were
represented in the sample of informants, the majority were African Americans under age 35. Less than half had completed high school, and more
than three fourths reported prostitution, drug dealing, theft, and/or street
hustles as their primary source of income. On a monthly basis, their income
averaged $2181, with a range of $400 to $7500.
All of the 52 informants had long histories of drug use. As illustrated
in Table Il, they began their illicit drug-using careers with marijuana at a
mean age of 14. Importantly, however, for all but 2 of these subjects, alcohol and tobacco use preceded marijuana use. As significant proportions
of the group experimented with inhalants, hallucinogens, stimulants (uppers), and depressants (downers), almost all began using marijuana on a
continuous basis.
253
Crack, Crack Hanse Sex, and HIV
Table I. Selected Characteristics of 52 Miami Crack Users
Male
Characteristic
Race/ethnicity
African American
White
Hispanic
Asian
Female
Total
n
%
n
%
n
%
9
5
3
53
29
18
24
7
3
69
20
9
33
12
6
64
23
12
1
3
1
2
Age
19-24
25-29
30-35
36--40
Education
Mean grade completed
High school grad/GED
Primary source of income
Legal
Prostitution
Drug dealing
Theft/husfles
None
Also receiving AFDC
or food stamps
Income (last month)
Range
~r
6
1
9
1
35
6
53
6
6
15
8
6
17
43
23
17
12
16
17
7
23
31
33
14
11.5
11
65
10.6
12
34
10.9
23
44
4
4
1
6
2
24
24
6
35
12
1
22
1
6
5
3
63
3
17
14
5
26
2
12
7
10
50
4
23
14
1
6
12
34
13
25
$400-7500
$2441
$257-6000
$2055
-$2181
Injection drug use was not uncommon among the study subjects. Overall, some 40% had early histories of intravenous cocaine, heroin, speed,
and/or "speedball" (heroin and cocaine). Not surprising was the prevalence
of cocaine use within this population. All of the men and all hut one of
the women had experimented with cocaine (nonintravenous) during their
teenage years, with 75% using the drug on a continuous basis. Crack use
began for both men and women by age 25.
In terms of current drug use (any use during the past 30 days), crack
clearly predominated. All of the men and women used the drug continuously, almost every day (Table III). Furthermore, other drugs were used
with considerable frequency. For example, 83% of these men and women
used alcohol on an average of 23 days during the past 30, and 69% drank
an average of 10 times a day. Similarly, 63% smoked marijuana on an av-
254
Inciardi
Table Il. Mean Age of First Use and First Continuousa Use of Selected Drugs by 52
Miami Crack Users
Male
(n = 17)
Drug
Female
(ù = 35)
Total
(ù = 52)
~
%
~
%
.~
%
Alcohol
I st use
Cont. use
13
17
100
76
15
17
100
86
14
17
100
83
Tobacco
i st use
Cont. use
14
15
94
82
14
17
97
94
14
17
96
90
Marijuana
1st use
Cont. use
14
16
100
94
15
16
100
97
14
16
100
96
Inhalants
1st use
Cont. use
16
16
53
24
19
14
37
9
17
15
42
14
Hallucinogens
1st use
Cont. use
18
16
47
24
18
18
43
9
18
17
44
12
Depressants
I st use
Cont. use
18
17
71
41
19
18
66
46
18
18
67
44
Stimulants
I st use
Cont. use
20
19
47
29
19
20
43
23
19
20
44
25
Speed, IV
1st use
Cont. use
17
17
24
18
17
19
14
9
17
18
17
12
Coke, Non-IV
I st use
Cont. use
18
20
100
71
19
18
97
77
18
18
98
75
Coke, IV
i st use
Cont. use
20
18
41
29
19
20
37
26
19
19
38
27
Crack
1st use
Cont. use
24
25
100
100
23
24
100
100
24
24
100
100
Heroin, Non-IV
1st use
Cont. use
21
17
35
6
19
18
29
14
19
17
31
4
Heroin, IV
1st use
Cont. use
20
19
35
18
18
18
26
14
18
18
29
15
255
Craek, Crack House Sex, and HIV
Table II. Confinued
Male
(n = 17)
Drug
~
Speedball, Non-IV
1st use
Cont. use
Speedball, IV
I st use
Cont. use
21
Female
(n = 35)
%
:~
%
~
%
18
20
17
17
3
20
17
17
02
24
24
16
21
26
20
20
20
25
21
-22
23
Total
(n = 52)
a"Continuous use" is defined here as 3 or more days a week for at least 1 month.
Table III. Current Drug Use (Last 30 Days) Among 52 Miami Crack Users
Male
(n = 17)
Female
(n = 35)
Total
(n = 52)
~
%
~
%
~
%
Alcohol
No. days used
No. times used each day
21
9
88
65
24
12
80
60
23
10
83
69
Marijuana
No. days used
No. times high each day used
11
6
65
59
12
5
63
58
11
5
63
58
Inhalants
No. days used
No. times high each day used
30
1
6
6
Õ
0
3Õ
1
2
2
Depressants
No. days used
No. times high each day used
9
3
24
18
15
I)
3
10
3
10
6
Cocaine, Non-IV
No. days used
No. fimes high each day used
6
2
29
24
7
10
46
46
7
9
40
38
Cocaine, IV
No. days used
No. fimes high each day used
2
3
12
12
11
9
9
9
7
6
10
10
Crack
No. days used
No. tLmes high each day used
26
18
100
100
24
17
100
97
25
18
100
98
Heroin, Non-IV
No. days used
No. fimes high each day used
2
2
6
6
1
3
3
3
2
3
4
4
Heroin, IV
No. days used
No. fimes high each day used
1
1
6
6
0
0
1
1
2
2
Drug
256
Inciardi
erage of 23 days during the past 30, and 58% smoked an average of 5
times a day.
All of the subjects in this sample smoked crack for as long as it was
available and they had means to purchase it--with money or sex, stolen
goods, furniture, or other drugs. It was rare that someone had just a single
"hit." It was typical that they spent $50 to $100 in one period, often binging
for 3 or 4 days. During these smoking cycles, users neither ate nor slept.
Some informants purchased crack over 200 times in the 30-day period prior
to study recruitment, and they gauged how much they smoked by either
how orten, how long, or how much money they spent. It was difficult for
them to calculate precisely how many "rocks" or how much crack they actually consumed.
While many of these crack users binged for several days in a row, over
half (58%) used the drug on a daily basis. None used crack less than 10
days out of the last month. A common trend, however, was a 3- to 4-day
smoking bender followed by 2 days of sleep. For every day they used crack,
they were "high" from as few as 3 times to as many as 50 times. This
suggests that some were consuming perhaps 3 to 50 crack rocks a day,
spending up to $250 or more a day on crack. Almost half of this group
were high 20 to 30 times each day they smoked.
Once crack was tried by these subjects, it was not long before it became a daily habit: 37% of the sample used crack daily immediately after
first trying it; an additional 27% used it daily by the end of their first month,
and almost 80% of the 52 respondents used it daily within 6 months after
their first use.
The crack users interviewed in this study had long and active sexual
histories. As indicated in Table IV, for example, the mean age of first sexual intercourse was 14 years, with the females initiating sex almost a year
earlier than the males. The first sex for money exchange occurred at a
mean age of 19.8 years, and sex for drugs at a mean of 23.2 years.
Table V highlights the nature and extent of the sexual activities engaged in by these 52 crack users during the 30-day period prior to interview.
Table Ig. Sexual Historiesof 52 Miami Crack Users
Male
Female
Mean age at
(n = 17)
(n = 35)
first time
~
%
~
%
Sexual intercourse
Sex for money
Sex for drugs
14.3
19.1
23.1
100
94
70.6
13.7
20.1
23.3
100
97
86
Total
(n = 52)
~
%
14.0
19.8
23.2
100
96
81
Crack, Crack House Sex~ and HIV
257
Table V. Sexual Activities During the Last 30 Days Among 52 Miami Crack Users
Males
n
Female
% sample
n
% sample
No. of sex partners
Male partners
0
1-25
26-50
51-75
76-99
_>100
4
4
2
0
2
5
24
24
12
Female partners
0
1-25
26-50
51-75
76-99
_>100
5
2
2
0
4
4
29
12
12
12
29
24
24
0
0
0
1
3
31
31
4
O
0
0
0
3
9
89
89
11
Type of sexual aetivity
Straight (vaginal)
0
1-25
26-50
51-75
76-99
>100
7
3
2
2
2
1
41
18
12
12
12
6
4
12
5
4
4
6
11
34
14
11
11
17
1
1
2
5
4
4
6
6
12
29
24
24
2
5
8
6
7
7
6
14
23
17
20
20
Anal/insertive
0
1-25
26-50
51-75
76-99
_>100
9
6
1
0
0
1
53
35
6
NA
NA
NA
NA
NA
NA
Anal/receptive
0
1-25
26-50
51-75
76-99
_>100
12
3
1
0
0
1
71
18
6
Oral
0
1-25
26-50
51-75
76-99
->i00
6
6
28
2
5
0
0
0
80
6
14
Total
n
% sample
258
Inciardi
Table V. Cominued
Male
n
Female
% sample
n
Total
% sample
n
% sample
Type of sexual activity
Manual (masturbation)
0
1-25
26-50
51-75
76-99
_>i00
12
4
1
0
0
0
71
24
6
25
9
0
1
0
0
71
26
Depended exclusively on
sex for obtaining
money or drugs
6
35
28
80
34
65
Depended exclusively on
sex for obtaining
drugs
4
24
15
43
19
36
3
Among the 17 male crack users, more than half had 25 or more male sex
partners, and 5 of the 17 had 100 or more male partners. In addition, almost three fourths of these male crack users had more than 25 female sex
partners during the same period. Moreover, 42% participated in vaginal
sex more than 25 times; 88% partieipated in oral sex more than 25 times,
with 24% engaging in oral sex 100 or more times; just under half participated in anal insertive sex at least once; and 30% engaged in anal receptive
sex during this 30-day period. Finally, 30% of these men masturbated other
men, with orte individual providing this service more than 25 times.
The women appeared to be more sexually active than the men. Almost
90% of the women had 100 or more male sex partners, and 11% had as
many as 25 female partners. Some 39% of these women participated in
vaginal sex more than 50 times, 57% engaged in oral sex more than 50
times, 20% participated in anal sex, and 29% reported masturbating men,
with one woman doing so on more than 50 occasions.
The data in Tables V and VI combine to suggest that both men and
women who exchange sex for crack are at significant risk for HIV infection.
In addition to frequent high-risk sexual activities with multiple partners,
much of these activities are unprotected. As indicated in Table VI, for example, only 23% of the women always insisted that their partners use condoms during vaginal sex. Moreover, an even smaller proportion (14%) of
259
Crack, Craek House Sex, and HIV
Table VI. Condom Use During the Last 30 Days by 52 Mianü Crack Users
Male
(n = 17)
Female
(n = 35)
n
%
n
%
5
4
3
5
29
24
18
29
8
18
8
1
23
51
23
3
11
3
2
1
65
18
12
6
16
13
5
1
46
37
14
3
3
3
5
6
18
18
29
35
3
2
2
28
9
9
6
80
During vaginal intercourse
Never
50/50
Always
N/A
During oral sex
Never
5O/50
Always
N/A
During anal sex
Never
50/50
Always
N/A
these women always insisted that their partners use condoms during oral
sex. Seven of the 35 women in this sample engaged in anal sex during the
30-day period prior to interview. Only 2 of them always insisted that their
partners use condoms. Although the potential for HIV transmission during
unprotected vaginal and anal sex is weil documented (P. T. Cohen et aL,
1987), clearly placing women who engage in these activities with multiple
and anonymous sex partners at considerable risk; infeetion risk through
oral sex is less clear (Peterson, 1990). However, open sores on the lips and
tongues of chronie users of crack are not uncommon, a result of bums and
skin ulcerations caused by the heated sterns of crack-smoking paraphernalia. Given the high eoneentrations of virus in the seinen of men infectecl
with HIV (Mavligit et al., 1984; Redfield et al., 1985; Levy, 1989), the potential for transmission of infection under these circumstances is considerable. And similar to the women, only 18% of the men always used condoms
during vaginal sex, only 12% always used eondoms during oral sex, and
only 29% always used condoms du.ring anal sex.
Given their widespread participation in high-risk behaviors, it is not
surprising that a signifieant proportion of the respondents were poorly informed about HIV and AIDS. As indieated in Table VII, for example,
42% were under the impression that almost all of the people infected with
AIDS were gay, 83% did not understand the latency period assoeiated with
260
Inciardi
Table VII. HIV and AIDS Knowledge, Levels of Concem, and Self-Reported Serostatus
of 52 Miami Crack Users
Male
%
sample
Knowledged (responding "true")
1. In the United States, 90% of those with
AIDS are gay.
7
41
Female
%
n
sample
n
%
sample
15
22
42
43
Total
2. People who get infeeted with AIDS know it right away because they feel sick.
12
71
30
86
42
83
3. AIDS can be spread by people kissing, sneezing, or sharing food.
15
88
30
86
45
87
4. Condoms can help prevent the spread of AIDS during sex.
17
100
32
49
94
91
5. Cleaning needles with bleach can help to reduce the spread of AIDS among IV drug
users
9
53
18
51
27
52
Level of concern
How would you rate your own level of concem
Little
1
Moderate
2
Considerable
3
Extreme
11
Changes in behaviors to reduce AIDS risk
Start using condoms
6
Increased use of condoms
2
Changed type of sex practices
3
More selective about sex partners
4
Reduced number of sex partners
3
about AIDS?
6
2
12
1
18
8
65
24
35
12
18
24
18
16
5
3
6
6
5
3
23
69
3
3
11
35
6
6
21
67
46
14
9
17
17
22
7
6
10
9
42
12
11
19
17
H I V infection, a n d 8 7 % b e l i e v e d t h a t A I D S c o u l d b e s p r e a d t h r o u g h c a s u a l
contact. By contrast, a l m o s t all ( 9 4 % ) r e a l i z e d t h a t c o n d o m u s e d u r i n g sex
helped prevent the spread of AIDS. Moreover, although 48% did not know
that cleaning needles could reduce the spread of AIDS among intravenous
drugs, all o f t h e c u r r e n t injectors r e s p o n d e d to this q u e s t i o n correctly.
I t is also c l e a r f r o m t h e d a t a in T a b l e V I I t h a t t h e m a j o r i t y o f t h o s e
i n t e r v i e w e d w e r e c o n c e r n e d a b o u t A I D S . I n t e r m s o f b e h a v i o r a l c h a n g e to
r e d u c e t h e i r risk for A I D S , t h e m a j o r i t y o f b o t h t h e m e n a n d w o m e n e i t h e r
s t a r t e d using c o n d o m s o r i n c r e a s e d t h e f r e q u e n c y o f use. C o n s i d e r a b l y
fewer, however, c h a n g e d t h e i r sexual practices, r e d u c e d t h e i r n u m b e r o f
sex p a r t n e r s , o r w e r e m o r e selective a b o u t t h e i r p a r t n e r s .
Crack, Crack House Sex, and HIV
261
Not surprisingly, 88% of the sample had considerable or extreme concern about AIDS, with slightly higher proportions of women than men responding as such. And while 56% either started using condoms or increased
their use recently, only small proportions changed their types of sexual
practices (11%), reduced the number of sex partners (17%), or were more
selective about sex partners (19%).
Perhaps most significant about these crack users was their self-reported HIV test data: 92% reported having been tested for HIV infection
(88% of the men and 94% of the women). Of those who received their
test results (n = 37), 31% of the men and 21% of the women reported
being HIV positive.
Based on the observational data collected during the visits to the eight
Miami crack houses, it appears that the crack houses frequented by the
sampted subjects are of several types. Moreover, the term "crack house"
can mean many different things--a place to use, a place to sell or do both,
a place to manufacture and package crack, and the location may be a
house, an apartment, a small shack at the back of an empty lot, an abandoned building, or even the rusting hulk of a discarded automobile. They
are known in Miami under numerous different names, including castles,
base houses, brothels, residence houses, and resorts.
Reportedly few in number, "castles" are fortified structures where
large quantities of crack are manufactured from powdercocaine, packaged
in plastic bags or glass vials, and sold both wholesale and retail. Crack
users are not permitted inside the walls of castles. Typical fortifications
include barred windows, reinforced door and window frames, steel doors
with heavy slide bolts, and walls reinforced from the inside with steel mesh
and/or a layer of concrete blocks. Such heavy fortifications are for the purpose of making police raids difficult.
"Base houses" are used by many kinds of drug users, especially intravenous users. A variety of drugs are available, including crack. However,
smoking crack is not the primary activity. Intravenous drug use (typically
cocaine) is more commonly seen and accepted here than in other types of
crack houses, but sex-for-drugs exchanges rarely occur.
The "resort" is one of the more customary types of crack house ha
Miami. The physical layout is that of a small apartment adapted for crack
use. The kitchen is used for cooking crack, at least one bedroom is set
aside for sex, and the living space is used for sellh'ag and smoking. Sexual
activities also occur openly in the common smoking areas. The owners of
these crack houses seem to be concerned about only two things--money
and crack. Many were addicted to crack, and operating the house is to
support a drug habit. Almost anything, furthermore, can happen in these
crack houses. They were described and observed as filthy, chaotic, and
262
Inciardi
crowded. The crack smokers get into fights, attempt to steal each other's
drugs, and exhibit extreme paranoia.
A characteristie of the resort is easy access to crack, although each
house has slightly different sales procedures. Some charge an entrance fee
and customers are free to smoke and have sex~ Crack is usually on a table
and purchases are informal. A second characteristic is the bartering of sex
and crack, which occurs between the prostitute and her/his customer. The
owner of the crack house receives a fee (crack or money) from the customer for the use of a private room for sex, and/or for having sex with a
prostitute in the employ of the crack house. In some cases, the customer
pays both the owner of the house and the prostitute.
Although prostitution and trading sex for crack are among the primary
activities of many crack houses, in the "brothel" the owner is a dealer/pimp
and the sex/drugs exchange system is somewhat unique. The prostitute is
a "house girl" (and sometimes "boy"), and is not involved in the payment
process. For the sexual services she provides, she receives payment from
the owner of the house in the form of crack, room, and board. In addition
to the sexual services available in the brothels, some street prostitutes use
them solely as places to have sex with their customers.
"Residence houses" are quite numerous in the Miami area, and are
likely the most common form of crack house. They are houses or apartments where small groups of people gather regularly to smoke crack. The
operators are reluctant to call these places "crack houses," because they
are used as such only by their friends. However, the activities are the same
as those in other crack houses, including sex-for-crack exchanges. The major differences revolve around the payment system. Crack is not sold in
residence houses, it is only smoked. In the more traditional crack house,
payment for using the house can be made either with money or crack;
money being preferred. In the residence house, payment is made only with
craek. Visitors give crack or more orten share crack with the owner of
the house or apartment, in return for having a place to smoke or have
sex. There are usually fewer people in these crack houses than in others--5 or 6 compared to 15 or 20. They are also the same 5 or 6 individuals, whereas in other types there is a greater turnover of people.
Finally, whereas the visitors to other types of craek houses are "customers," only "friends" are invited to residence houses.
DISCUSSION
Although the sample size and case selection procedures make generalization difficult, the data from both the structured and unstructured in-
Crack, Crack House Sex, and HIV
263
terviews clearly suggest that persons who exchange sex for crack are not
casual users of drugs. Most had been using illegal drugs for at least a decade, almost half had injected drugs at some point in their drug-using careers, and virtually all were daily users of crack at the time of study
recruitment. Similarly, exchanges of sex for money or drugs were not new
experiences for these individuals. Some 94% of the males and 97% of the
females in the initial cohort of 52 respondents had been exchanging sex
for money for an average of 7 years. Moreover, 81% of these same men
and women had also exchanged sex for drugs for an average of 4 years.
The interview and observational data also suggest that individuals who
exchange sex for crack do so with considerable frequency, and through a
variety of sexual activities. The systematic data indicate that almost a third
of the men and 89% of the women had had 100 or more sex partners
during the 30-day period prior to study recruitment. Furthermore, not only
were sexual activities anonymous, extremely frequent, varied, uninhibited
(orten undertaken in public areas of crack houses), and with multiple partners, but in addition, condoms were not used during the majority of these
sexual contacts. As such, these pretiminary data suggest that persons who
exchange sex for crack (or for money to buy crack) are at considerable
risk of infection with and/or transmission of HIV disease.
In a retrospective glance at the interview and observational data, two
important issues emerge that require discussion since they target risk behaviors specific to crack house sex: (i) the differences between "street prostitutes" (who exchange sex for money to buy crack) and the so-called "crack
whores" (who most often make direct exchanges of sex for drugs in crack
houses); and (ii) oral and vaginal sexual practices that facilitate the exposure of already eompromised immune systems to HIV infection.
"Crack Whores" Versus "Street Prostitutes"
There seem to be some interesting differences between women who
exchange sex for crack in crack houses, and those who hustle "tricks" or
"johns" (customers) on the street for money to buy crack. Data from both
interviews and observations suggest that prostitutes may be at lesser risk
for HIV infection and transmission than their crack house counterparts.
This implication is drawn f-rom considerations about the former group's
frequency of sexual contacts, and their attitudes and practices associated
with condom use.
First, it appears that street prostitutes have fewer sex partners, and
considerably less frequent sexual activity, than the crack house whores
(more commonly referred to as "skeezers," "strawberries," and "head bunt-
264
lnciardi
ers") who exchange sex for crack in crack houses. Soliciting a customer on
the street, negotiating a priee, going to a place to have sex, engaging in
sex, receiving payment, and then going back to the streets to purchase and
smoke craek all take time. To a considerabte extent, this regulates the aggregate number of customers that a street prostitute can service. Several
of the street prostitutes in this study reported an average of three to six
"tricks" each night or day that they worked, with most soliciting clients 15
to 30 days during the month prior to interview. Although this, too, results
in an inordinate number of sex partners during the course of a year, or
even a month's time, it is orten considerably less than that of women who
exchange sex exclusively in crack houses.
Second, it appears that the street prostitutes in this study were more
conscious of sexually transmitted diseases and more often insisted that their
customers use condoms. By contrast, based on the author's observations
and the reports of numerous informants, condoms are rarely used during
the sexual activities that occur in crack houses. There are likely several
reasons for this difference. There is a socialization process, for example,
associated with becoming a prostitute. Would-be and neophyte prostitutes
leam the appropriate techniques and safeguards through apprenticeships
with pimps and/or more experienced prostitutes (Winick and Kinsie, 1971;
Goldstein, 1979; Evans, 1979; Rosenbaum, 1981; Carmen and Moody, 1985;
MiUer, 1986). In some cases there is formal or informal training on how
to protect oneself from theft, violence, or disease (Heyl, 1979). Furthermore, however loose, unstructured, and transitory they may offen be, those
who work the streets or in organized houses of prostitution have friendships
and peer relationships through which experiences are shared, techniques
are traded, wamings are communicated, and knowledge is reinforced.
Concem for cleanliness and signs of sexually transmitted disease were
readily apparent among several of the street prostitute/informants in this
investigation. There appear to be no such concerns in crack houses. The
women who trade sex for crack in crack houses are typicaUy not experienced prostitutes who moved from the streets to the crack house. Rather,
the majority are women who drift haphazardly into sex-for-crack exchanges
due to their compulsive dependence on the ding and their limited conventional sources of drug-use support. The following quotation, drawn from
the transcript of a 28-year-old female crack user illustrates the process. She
had been a marijuana user since age 15, a cocaine user since age 18, and
a crack user since age 26. In her comments below, she details her first
exehange of sex for crack and how it came about.
I had my last paycheck, that was $107. That day I went straight from there [work]
with a friend guy and copped [purchased] some drugs. I bought $25--5 nickel rocks.
I walked up to the apartment, me and the same guy. We drunk a beer, we needed
Crack,. Crack House Sex, and HIV
265
the can to smoke on [beverage cans are easily converted into crack-smoking
devices]. So we sat there and we smoked those five rocks and you know like they
say, one is too much and a thousand is never enough. And that's the tmth. Those
five rocks weht like this [snaps fingers] and I immediately, I had maybe about $80
left. I had intentions of takin' my grandmother some money home for the kids.
But I had it in my mind you know I was, I was just sick. I wanted to continue to
get high so push come to shove I smoked up that--that whole day me and him we
smoke up. It didn't last till maybe about 8:00 PM cause we started maybe about
12:00 that afteruoon.
Okay all the money was gone, all the drugs was goue. About 9:00 we weht
and sat in the park. Usually when we set in the park people will come over and
they'll have drugs. Some friends came over and they had drugs. He walked home.
I stayed out because I couldn't give an account for what I had did with the money.
My grandmother done thought that I was goin' to pick up my check and comin'
back. So I watked around and I walked down this street, you know you got people
that will pick you up. So this guy stopped and I gor in the car, and I never did any
prostituting but I wanted more drugs. So this guy he stopped and he picked me
up and he asked me: "How much would you charge me for a head?" That's oral
sex. And I told hirn $40. And so he say how much would you charge me for two
hours to have to just sex not oral sex? And so I told him $40 so he say: "Okay get
in," and he took me to this hotel.
He had about six rocks. I didn't wanna sex. I wanted to get high so we smoked
the rocks and durin' the time I sexed with him. So after I sexed him he gave me
the money and after the rocks was gone I still wanted to ger high. So this man he
gave his car and his keys and gave me more money to go get more dmgs. We weht
into another hotel. By that time it was maybe 6:00 in the morning. He ended up
leaving me in the hotel. By that time I done spent all my $40. It wasn't nothing I
had done wasted the money. So later on that aftemoon, my grandmother done let
me ger sleep and everything. I think later on that day and the hext day I weht to
my godfather's house and I earned $15, I helped him do some work around the
house so he gave me $15.
So I went and stayed home with the kids and waited tiU they gor ready to go
to bed that night. I went and gor three rocks with that $15. I started oft smokin'
by myself, but when you sittin' in the park people come to know you and they be
tryin' to horn in on what you doin'. So ended up smokin' I think about a rock and
a half with somebody that was sittin' in the park. Later on I ended up walkin' down
the main strip again and this guy came by and he say: "Weil how much money
would do you want for a head?" So I told him $10. I was really desperate this time
arouud so I told him $10. He say weU I don't have but $5. I say okay I'll take that
you know I settle for little or nothin'. So we went down the street and parked in
this parkin' lot and I gare hirn a head. And I immediately went to the drug house,
and bought a nickel rock.
A s e c o n d likely r e a s o n for t h e d i f f e r e n c e s b e t w e e n c r a c k w h o r e s a n d
s t r e e t p r o s t i t u t e s is t h e r o l e t h a t c r a c k plays i n t h e i r lives. F o r t h e c r a c k
w h o r e s , c r a c k is at t h e basis o f t h e i r sex e x c h a n g e s , as clearly e v i d e n c e d
i n s u c h c o m m e n t s as "I d o it for c r a c k , " a n d " c r a c k is m y p i m p . " By c o n trast, a l t h o u g h t h e u s e o f c r a c k a n d o t h e r d r u g s is t h e r e a s o n w h y m a n y
w o m e n e n g a g e i n p r o s t i t u t i o n , t h e i r n e e d for c r a c k s e e m s s o m e w h a t less
p r e s s i n g . A n d a s s o c i a t e d w i t h this is p r o s t i t u t e s ' s t r o n g c o m m i t m e n t to p a y i n g f o r t h e i r o w n crack. T h e y will e x c h a n g e sex f o r m o n e y , b u t n o t f o r
drugs.
266
Inciardi
Crack House Sex, Cofactors, and HIV Infection Risk
At present, the biological variables which determine HIV infectivity
(the tendency to spread from host to host) and susceptibility (the tendency
for a host to become infected) are incompletely tmderstood. HIV has been
isolated from the semen of infected men, and it appears that it may be
harbored in the cells of pre-ejaculatory fiuids or sequestered in infiammatory lesions (Fischl, 1988). Furthermore, it appears that women can harbor
HIV in vaginal and cervical secretions at varying times during the menstrual
cyele (Wofsy, et al., 1986; Vogt et aL, 1986, 1987). The probability of sexual
transmission of HIV among homosexual and bisexual men through anal
intercourse, and to women through vaginal intereourse has been weil documented (Ma and Armstrong, 1989; J. B. Cohen and Wofsy 1989). However,
although there is the potential for viral transmission from female seeretions,
the absolute amounts of virus in these seeretions appear to be relatively
low. The efficiency of transmission of male-to-female versus female-to-male
is likely affected by the relative infectivity of these different secretions, as
weil as sex during menses, specific sexual practices, the relative integrity
of skin and mucosal surfaces involved, and possibly the presenee of other
sexually transmitted diseases. Within this context, the character of crack
house sex, both vaginal and oral, may facilitate the heterosexual transmission of HIV.
The potential for transmission of HIV from women to men during
vaginal intercourse in crack houses is related to one aspect of the cocaine/sexuality connection. Cocaine has long had a reputation as an aphrodisiac, although sexuality is notoriously a playground of legend,
exaggeration, and rumor. In all likelihood, much of cocaine's reputation
may be ffom the mental exhilaration and disinhibition it engenders, thus
bringing about some heightened sexual pleasure during the early stages of
use. At the same time, however, cocaine users have consistently reported
that the drug tends to delay the sexual climax, and that after prolonged
stimulation, an explosive orgasm occurs. Users also report that chronic use
of the drug results in sexual dysfunction, with impotence and the inability
to ejaculate the common complaints of male users, and decreased desire
for sex beeoming the norm for both male and female users (Grinspoon
and Bakalar, 1976; Weiss and Mirin, 1987).
What applies to powder-cocaine with regard to sexual stimulation and
functioning also applies to crack-cocaine. Male customers, as weil as male
and female providers in the sex/craek exchange networks report the difficulties associated with ejaculating under the influence of crack, noting that
men seem to climax only through extremely vigorous masturbation or prolonged vaginal intercourse. The author has observed, and numerous inform-
Crack, Crack House Sex, and HIV
267
ants have indicated, that the friction associated with such protracted stimulation often results in a rupturing of the surface sldn of the penis and in
the vaginal canal.
It is within such a situation that the potential for female-to-male transmission of HIV emerges. During vaginal intercourse, the frietion of the
penis against the clitoris, labia minora, and vaginal vestibule, opening, and
canal causes stimulation that can generate copious amounts of vaginal secretions. Furthermore, since women who exchange sex for crack in crack
houses do so with many different men during the course of a day or night,
potentially HIV-infeeted seinen from a previous customer can still be preseht in the vagina. Moreover, it was reported by one crack house customer
that he ruptured the skin on his penis while having intercourse with a
"crack house prostitute" while she was menstruating. As such, genital secretions as well as seinen and blood come into direct contact with the traumatized skin of a client's penis during crack house sex.
Although vaginal and anal intercourse often occur, rauch of the sex
that occurs in crack houses involves women performing oral sex on men.
To date, however, evidence for an oral route of HIV has been inconsistent.
In most of the investigations of homosexual practices where a full range
of sexual activities was carefully considered, for example, the risk from
either insertive or receptive orogenital contact was uncertain, although regarded to be quite low (Kaslow and Francis, 1989). The data concerning
heterosexual spread of the virus by oral sex are also limited. However, in
one of the few studies to examine this phenomenon, HIV seropositivity
among the spouses of AIDS patients was higher for couples who practiced
oral sex in addition to penile/vaginal sex, as compared with couples who
practiced only penile/vaginal sex (Fischl et al., 1988).
There is an accumulating body of evidence that impaired host immunity, as well as concomitant sexually transmitted diseases, and particularly
genital ulceration, may potentiate the transmission of HIV, by increasing
both infectivity and susceptibility (Johnson and Laga, 1988). In this regard,
many crack users have histories of sexually transmitted diseases (FuUilove
et aL, 1990; Rolfs et aL, 1990), and furthermore, the crack use life-style
likely engenders impaired immunity. The tendency of chronic users to
"binge" on crack for days at a time, neglecting food, sleep, and basic hygiene, severely compromises physical health. As such, crack users appear
emaciated most of the time. They lose interest in their physical appearance.
Many have scabs on their faces, arms, and legs, the results of bums, and
picking on the skin (to remove bugs and other insects believed to be crawling "under" the skin). Crack users tend to have burned facial hair from
carelessly lighting their smoking paraphernalia; and they seem to cough
eonstantly.
268
Inciardi
There is another cofactor apparent in crack house oral sex that may
be impacting on the spread of HIV. As noted eadier, many crack users
have open sores on their lips and tongues as the result of bums and other
epidermal trauma caused by the heat in the crack pipe stem. Sinee oral
sex is common in crack houses, the potential for HIV transmission from
infected semen eoming into contact with these lesions may be considerable.
What all of this suggests is that crack users and their sex partners are
at special risk for HIV aequisition and transmission. The compulsive nature
of craek use suggests that effective prevention/intervention efforts would
be difficult to implement, particularly those not undertaken within the context of intensive residential drug treatment. Moreover, although long-term
follow-up studies of crack users in treatment have yet to be conducted,
anecdotal reports from clinicians in the field suggest that patient attrition
and relapse rates are high. As such, crack users in general, and those who
exchange sex for craek in particular, represent a problem population for
which specially focused prevention/outreach initiatives taust be designed.
REFERENCES
Bowser, B. P. (1989). Crack and AIDS: An ethnographic impression. J. Nat. Med. Assoc. 81:
538-540.
Carmen, A., and Moody, H. (1985). Working Women: The Subterranean World of Street
Prostitution, Harper & Row, New York.
Cohen, J. B., and Wofsy, C. B. (1989). Heterosexual transmission of HIV. In Levy, J. A. (ed.),
AIDS: Pathogenesis and Treatmen~ Marcel Dekker, New York, pp. 135-137.
Cohen, P. T., Sande M. A., and Volberding, P. A. (1987). The AIDS Knowledge Base,
Massachusetts Medical Society, Waltham, MA.
Des Jarlias, D. C., and Friedman, S. R. (1988). Intravenous cocaine, crack, and HIV infeetion.
Z Am. Med. Assoc. 259: 1945-1946.
Evans, H. (1979). Harlots, Whores and Hookers: A History of Prostitution, Dorset Books, New
York.
Fisehl, M. A. (1988). Prevention of transmission of AIDS during sexual intercourse. In DeVita,
V. T., Hellman, S., and Rosenberg, S. A. (eds.), AIDS: Etiology, Diagnosis, Treatment,
and Prevention, J. B. Lippineott, Philadelphia, PA, pp. 369-374.
Fischl, M., Fayne, T., Flanagan, S., Leda, M., Stevens, R., Fletcher, M., La Voie, L., and
Trapido, E. (1988). Seroprevalenee and risks of HIV infeetion in spouses of persons
infected with HIV. Paper presented at the Fourth International Conferenee on AIDS,
June, Stockholm, Sweden.
Fullilove, R. E., Fullilove, M. T., Bowser, B. P., and Gross, S. A. (1990). Risk of sexually
transmitted disease among black adolescent eraek users in Oakland and San Franeisco,
California. Z Am. Med. Assoc. 263: 851-855.
Goldstein, P. J. (1979). Prostitution and Drugs, D.C. Heath, Lexington, MA.
G-rinspoon, L., and Bakalar, J. B. (1976). Cocaine: A Drug and Its Social Evolution, Basic
Books, New York.
Guinan, M. E. (1989). Women and crack addiction. Z Am. Med. Women's Assoc. 44: 129.
Heyl, B. S. (1979). The Madam as Entrepreneur: Career Management in House Prostitution,
Transaetion Books, New Brunswick, NJ.
Crack, Crack House Sex, and HIV
269
Inciardi» J. A., Lockwood, D., and Pottieger, A. E. (1993). Women and Crack-Cocaine,
Macmillan, New York.
Johnson, A. M., and Laga, M. (1988). Heterosexual transmission of HIV. AIDS, 2: S49-$56.
Kaslow, R. A., and Franeis, D. P. (1989). The Epidemiology of AIDS: Expression, Occurrence,
and Control of Human Immunodeficiency Virus Type 1 lnfection, Oxford University Press,
New York.
Levy, J. A. (1989). The human immunodeficiency viruses: Detection and pathogenesis. In Levy,
J. A. (ed.), AIDS: Pathogenesis and Treatment, Marcel Dekker, New York, pp. 159-229.
Ma, P., and Armstrong, D. (1989). AIDS and Infections of Homosexual Men, Butterworths,
Boston, MA.
Mavligit, G. M., Talpaz, M., Hsia, F. T., Wong, W., Lichtiger, B., Mansell, P. W. A., and
Mumford, D. M. (1984). Chronic immune stimulation by sperm alloantigens: Support for
the hypothesis that spermatozoa induce immune dysregulation in homosexual men. Z
Am. Med. Assoc. 251: 237-241.
Miller, E. M. (1986). Street Women, Temple University Press, Philadelphia, PA.
Peterson, T. A. (1990). Facilitators of HIV transmission during sexual contact. In Alexander,
N. J., Gabelnick, H. L., and Speiler, J. M. (eds.), Heterosexual Transmission of AIDS,
Wiley-Liss, New York, pp. 55-68.
Redfield, R., Markham, P. D., Salahuddin, S. Z., Sarngadharan, M. G., Bodner, A. J., Folks,
T. N., Ballou, W. R., Wright, D. C., and Gallo, R. C. (1985). Frequent transmission of
HTLV-III among spouses of patients with A1DS-related complex and AIDS. J. Am. Med.
Assoc. 253: 1571-1573.
Rolfs, R. T., Goldberg, M., and Sharrar, R. G. (1990). Risk factors for syphilis: Cocaine use
and prostitution. Am. Z Public Health, 80: 853-857.
Rosenbanm, M. (1981). Women on Heroin, Rutgers Urdversity Press, New Brunswick, NJ.
Sehultz, S., Zweig, M., Sing, T., and Htoo, M. (1990). Congenital syphilis: New York City,
1986-1988. Am. J. Dis. Child. 144: 279.
Sterk, C. (1988). Coeaine and HIV seropositivity. Lancet 1: 1052-1053.
Trapido, E. J., Lewis, N., and Comerford, M. (1990). HIV-1 and AIDS in Belle Glade, Florida:
A reexamination of the issues. Am. Behav. Sci. 33: 451-464.
Vogt, M. W., Craven, D. E., Crawford, D. E., Witt, D. J., Byington, R., Schooley, R. T., and
Hirsch, M. S. (1986). Isolation of HTLV-III/LAV from cervical secretions of women at
risk for AIDS. Lancet 1: 525-527.
Vogt, M. W., Witt, D. J., Craven, D. E., Byington, R., Crawford, D. S., Hutchinson, M. S.,
Schooley, R. T., Hirsch, M. S. (1987). Isolation patterns of the human immunodeficiency
virus from cervical secretions during the menstrual cycle of women at risk for the acquired
immunodeficiency syndrome. Ann. Intern. Med. 106: 380-382.
Walters, J. M., (1980). What is ethnography? In Akins, C., and Beschner, G. (eds.),
Ethnography: A Research Tool for Policy Makers in the Drug and Alcohol Fields, National
Institute on Drug Abuse, RockviUe, MD, pp. 15-20.
Weiss, R. D., and Mirin, S. M. (1987). Cocaine, American Psychiatric Press, Washington, DC.
Winick, C., and Kinsie, P. M. (1971). The Lively Commerce: Prostitution in the United Stares,
Quadrangle Books, Chicago.
Wofsy, C. B., Cohen, J. B., Hauer, L. B., Padian, N., Miehaelis, B., Evans, J., and Levy, J.
A. (1986). Isolation of AIDS-associated retrovirus from genital secretions of women with
antibodies to the virus. Lancet 1: 527-529.