A recent critique of the HIV prevention literature decries the over-emphasis on women as passive victims of male risk behavior, arguing that men who have sex with women have not only been understudied, but also that their own HIV risk has been underplayed . As a result of assuming a simplistic, power-driven model of men as powerful perpetrators and women as powerless victims, the authors argue that the literature on gender and HIV risk has largely ignored the structural, social, and cognitive factors that put men at risk and drive male risk behaviors, especially among high risk subgroups of men who have sex with women (MSW). Furthermore, understanding such men’s risk behavior is crucial for reducing rates of HIV among women, who are most likely to get HIV from sex with male partners .
Homeless men in the United States represent a sub-group of MSW who are at greater risk of HIV than other men. Among MSW, homeless men have higher rates of HIV/AIDS and exhibit more sexual risk behaviors than housed men [3, 4], including lower rates of condom use . Estimates of HIV seroprevalence among homeless men vary widely by city , but are generally 10% or higher [3, 7]. A significant portion of this risk comes from heterosexual behavior. The CDC estimates that heterosexual sex is responsible for 31% of new HIV cases among men, versus 12% for injection drug use and 53% for sex with men . Even among homeless injection drug users, sexual behavior is a strong predictor of new HIV infections over time, [3, 9].
Homeless men in the U.S. represent a large and growing population. Between 2.3 and 3.5 million people per year, mostly men, experience homelessness in the U.S. , and the economic recession of the last several years is steadily forcing more men out of housing and onto the street . In order to reduce HIV infection rates among homeless men and their partners, including homeless women – who not surprisingly also exhibit elevated HIV risk due to unprotected heterosexual intercourse [12, 13] - it is important to understand the determinants of sexual risk behavior among homeless men.
A critical component of sexual decision-making involves judging the riskiness of sexual partners, a topic that has seen both qualitative and quantitative research among diverse populations. Watson and Bell  found that trust and the drive for intimacy underlie women’s decisions to forego safe sex, both among high SES middle aged women and younger women living in inner-city areas. Notably, sheltered homeless women living in Skid Row expressed similar tendencies to forego protection use due to feelings of intimacy and warmth, even for male partners they knew were not monogamous . Meanwhile, Masaro et al.  found that visitors to a sexually transmitted infection (STI) clinic (both male and female) used trust, but also the social reputation and physical and socioeconomic characteristics of partners when judging whether to use condoms. In a sample visiting an STI clinic (predominantly male) in Southern California, Hoffman and Cohen  found that individuals used appearance and cleanliness, social reputation, and the location or venue of meeting to judge the riskiness of casual sexual partners.
Consistent with normative decision theory , these findings indicate that risky sexual decisions are motivated by the expectation of emotional and physical benefits, which makes attractive those heuristics that are easily available (e.g., a sense of trust, social reputation, appearance) for engaging in potentially unsafe sexual encounters. This may be especially pertinent among lower SES men, whose opportunities for sexual encounters are particularly restricted . Homeless men represent the extreme low end of the SES continuum, creating unique considerations for the intersection of masculinity and social class [19, 20], and are at elevated risk for receiving and transmitting STIs [3, 4]. This begs the question of how homeless men judge partner risk, and whether their heuristics are similar to those found in other populations.
While previous research has used scales to examine general perceived STI risk among homeless men , or has focused on perceptions of STI transmission to homeless men’s partners , we know of no study that examines homeless men’s perceptions of sexual risk from a qualitative standpoint, nor of any research that examines the perceived riskiness of sexual partners among homeless men. We used the existing literature on partner risk perception, as well as drawing upon theories of gender and class and normative decision theory, to design a qualitative investigation of perceived sexual partner risk among homeless men living on Skid Row. In particular, Bourgois’s theory of “lumpen masculinity”  - which details how social and economic marginality accentuates male violent, risk-taking and abusive behavior via role frustration - prompted us to train interviewers to be attentive to how partner risk perception might be affected by a drive to realize traditional male roles and associated misogynistic views of women.
When developing research with understudied populations or regarding a phenomenon that is not well understood, qualitative interviewing can be particularly useful. Specifically, event-based interviews that obtain narrative descriptions of risk perception and decision-making  can aid the development of more structured questionnaires and surveys to investigate the determinants of health risk behaviors. This is a strategy our research group has followed with sexual decision-making among homeless women . To address the gap in understanding homeless men’s perceptions of sexual risk, we conducted exploratory qualitative interviews with men using shelters and meal lines in downtown Los Angeles (Skid Row), focusing on risk perceptions and decision-making in sexual encounters and relationships with women. The goal of this study was to elicit narratives about recent sexual encounters and to analyze these narratives for common patterns and themes regarding sexual risk perception and decision-making.