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Cuidate tourism, drugs, sex and HIV among young people in Monteverde, Costa Rica
Freidus, Andrea Lee
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University of South Florida
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Latin America
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ABSTRACT: The main goal of this thesis is to understand a community's perceptions of the potential impact of tourism on the spread of sexually transmitted infections (STIs) including HIV/AIDS in Monteverde, Costa Rica. In particular, I examine the ways in which globalization and increased travel affect the overall health and behavioral patterns among young people from a community reliant on tourism. The impact of migration and population movement on the spread of infectious diseases has already been well documented. Moreover, there is a clear understanding of the impact of sex tourism on the spread of STIs. However, this project seeks to understand the impact of tourism on a local population that does not have a formal commercial sex industry. Instead, the majority of sexual interactions between young local men and visiting women reflect more of an attitude of adventure and tend to be romantic in nature.Local men are inclined to have casual sexual relations with female tourists because foreign women are perceived as more liberal and sexually adventurous. Visiting women are attracted to the idea of an exotic, sexual relationship while on vacation. The interactions that result from these mentalities often lead to risky sexual behavior that could facilitate the transmission of STIs. This project was exploratory in nature. Data were collected from various sectors of the Monteverde community with a focus on their perceptions of the role tourism plays on changing local behavior. This project also seeks to understand the current level of sex education and STI prevention among the youth of the community. These data were used to create targeted interventions within the community in recognition of World AIDS DAY on December 1, 2003, and can inform the design of future education and prevention programs that are culturally appropriate.
Thesis (M.A.)--University of South Florida, 2005.
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by Andrea Lee Freidus.

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b tourism, drugs, sex and HIV among young people in Monteverde, Costa Rica /
by Andrea Lee Freidus.
[Tampa, Fla.] :
University of South Florida,
Thesis (M.A.)--University of South Florida, 2005.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
System requirements: World Wide Web browser and PDF reader.
Mode of access: World Wide Web.
Title from PDF of title page.
Document formatted into pages; contains 154 pages.
ABSTRACT: The main goal of this thesis is to understand a community's perceptions of the potential impact of tourism on the spread of sexually transmitted infections (STIs) including HIV/AIDS in Monteverde, Costa Rica. In particular, I examine the ways in which globalization and increased travel affect the overall health and behavioral patterns among young people from a community reliant on tourism. The impact of migration and population movement on the spread of infectious diseases has already been well documented. Moreover, there is a clear understanding of the impact of sex tourism on the spread of STIs. However, this project seeks to understand the impact of tourism on a local population that does not have a formal commercial sex industry. Instead, the majority of sexual interactions between young local men and visiting women reflect more of an attitude of adventure and tend to be romantic in nature.Local men are inclined to have casual sexual relations with female tourists because foreign women are perceived as more liberal and sexually adventurous. Visiting women are attracted to the idea of an exotic, sexual relationship while on vacation. The interactions that result from these mentalities often lead to risky sexual behavior that could facilitate the transmission of STIs. This project was exploratory in nature. Data were collected from various sectors of the Monteverde community with a focus on their perceptions of the role tourism plays on changing local behavior. This project also seeks to understand the current level of sex education and STI prevention among the youth of the community. These data were used to create targeted interventions within the community in recognition of World AIDS DAY on December 1, 2003, and can inform the design of future education and prevention programs that are culturally appropriate.
Adviser: Dr. Linda Whiteford.
Co-adviser: Dr. Nancy Romero-Daza
Latin America.
Dissertations, Academic
x Applied Anthropology
t USF Electronic Theses and Dissertations.
4 856


Cuidate: Tourism, Drugs, Sex and HIV among Young People in Monteverde, Costa Rica by Andrea Lee Freidus A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Anthropology College of Art and Sciences University of South Florida Co-Major Professor: Nancy Romero-Daza, Ph.D. Co-Major Professor: Linda Whiteford, Ph.D. Boo Kwa, Ph.D. Date of Approval: November 18, 2005 Keywords: Latin America, STIs, Adolescents, Migration, Risk Copyright 2005, Andrea Freidus


Dedication This thesis is dedicated to my mother, Arlene Freidus, whose spirit of courage, strength, compassion, and perseverance guides me everyday. It is also dedicated to my father, Kip Freidus, who has always encour aged me to live life full and follow my dreams.


Acknowledgements I would like to thank my family for all of their support, especi ally my father who has always been there cheering me on. I al so want to thank Dr. Nancy Romero-Daza who allowed me the opportunity to work for he r on this grant, but more importantly for her guidance and support throughout my journey. I am blessed to be able to call her friend. I also want to th ank Cristina Calderon for sacrificing her time and energy to work with me in Monteverde with such passion and commitment. Also, my sincere thanks to Dr. Boo Kwa for being flexible, supportive, and understanding throughout this process. Finally, for Dr. Linda Whiteford who is and always will be my advisor, counselor, and friend. Thank you all for he lping me to grow in so many ways.


i Table of Contents List of Figures iv Abstract v Chapter 1: Introduction 1 The Situation in Costa Rica 3 HIV in Costa Rica 5 HIV and Young People in Costa Rica 5 HIV Prevention 6 Tourism and Sex Tourism in Costa Rica 7 Study Site: Monteverde, Costa Rica 10 Chapter 2: Literature Review 13 Applied Medical Anthropology and HIV Research 13 Anthropology and HIV Research 16 Injection Drug Users 17 Sex Workers and HIV 20 Trafficking for Sexual Exploitation 25 Men Who Have Sex with Men (MSM) 27 Minorities 30 Globalization and Tourism 33 Tourism and Prevention 38 Sexually Transmitted Infections: Latin America 38 HIV and Adolescents 39 College Students in the United States 42 College Students: Alcohol, Drug Use and Sex 42 College Students: Sex, Condoms and HIV 43 College Students: Sex and Vacation 45 Critical Medical Anthropology and Political Economy 45 Structural Violence 50 Chapter 3: Methods 54 Research Team and Tool Development 54


ii Sampling and Informed Consent 55 Research Methods 56 In-depth Interviews 56 Tourism Sector 57 Education Sector 57 Government Sector 58 Religious Sector 58 Health Sector 59 Surveys 60 Focus Groups 61 Participant Observation 63 High School Discussion and Education Sessions 65 Data Analysis 67 Study Limitations 68 Chapter 4: Results and Discussion 71 Research Objective 1 71 Changing Tourism in Monteverde 72 Long-term Tourists and Students 74 Research Objective 2 78 Changing Family Dynamics 78 Changing Behavior: Alcohol and Drugs 80 Changing Behavior: Sex 82 Condom Use and Availability in Monteverde 86 Prostitution and Gringeros 88 Machismo 89 Mobility 92 Research Objective 3 93 Vacation-mode and Latin Lovers 93 Research Objective 4 97 HIV and HIV Testing 97 Current Sex Education 99 Lack of Activities for Young People 102 Research Objective 5 103 Targeted Education 103 Sex Education and Religi ous Considerations 104 Chapter 5: Conclusion 105 Recommendations 108 Healthcare Workers 108 Educators 109


iii Tourism Sector 110 Local Institutions 110 Suggestions for Future Research 111 Contributions to Theory, Anthr opology, and Public Health 112 References 121 Appendices 136 Appendix A. Informed Consent (English) 137 Appendix B. Open-ended Interview Guide (Spanish) 138 Appendix C. Focus Group Interview Guide (English) 141 Appendix D. Short-term Visitor Survey 143 Appendix E. Sample of Questions from High School Discussions 145


iv List of Figures Figure 1. Map of Costa Rica 4 Figure 2. View from Monteverde 9 Figure 3. View of Santa Elena 10 Figure 4. Sunset View from Monteverde 11 Figure 5. Adventure Tourism in Monteverde 72 Figure 6. Pension Santa Elena 73 Figure 7. CPI Language School in Monteverde 75 Figure 8. Sex and Freedom Mural 96 Figure 9. Guillero Murillos Community Talk on HIV/AIDS 116 Figure 10. HIV/AIDS Prevention Banner I 116 Figure 11. HIV/AIDS Prevention Banner II 117 Figure 12. Condom Distribution Night 118 Figure 13. How to Use a Condom Flyer 118


v Cuidate: Tourism, Drugs, Sex and HIV among Young People in Monteverde, Costa Rica Andrea Freidus Abstract The main goal of this thesis is to understand a communitys perceptions of the potential impact of tourism on the spread of sexually transmitted infections (STIs) including HIV/AIDS in Monteverde, Costa Rica. In particular, I examine the ways in which globalization and increased travel affect the overall health and behavioral patterns among young people from a community reliant on tourism. The impact of migration and population movement on the spread of inf ectious diseases has already been well documented. Moreover, there is a clear unde rstanding of the impact of sex tourism on the spread of STIs. However, this project seeks to understand the impact of tourism on a local population that does not have a formal commercial sex industry. Instead, the majority of sexual interactions between young local men and visiting women reflect more of an attitude of adventure and tend to be ro mantic in nature. Local men are inclined to have casual sexual relations with female tour ists because foreign women are perceived as more liberal and sexually adve nturous. Visiting women are attracted to the idea of an exotic, sexual relationship while on vacation. The interactions that result from these


vi mentalities often lead to risky sexual behavi or that could facilitate the transmission of STIs. This project was exploratory in nature. Data were collected from various sectors of the Monteverde community with a focus on their perceptions of the role tourism plays on changing local behavior. This project also seeks to unders tand the current level of sex education and STI prevention among the youth of the community. These data were used to create targeted interventions within the community in recognition of World AIDS DAY on December 1, 2003, and can inform the desi gn of future education and prevention programs that are culturally appropriate.


1 Chapter 1: Introduction When HIV exploded onto the scene in the early 1980s, many researchers and scientists scrambled to unde rstand the epidemiology and pathology of this fatal, contagious virus. Eventually, transmi ssion was determined to occur through the exchange of body fluids and quickly linked to certain at risk segments of the population including hemophiliacs, homose xuals, intravenous drug users, and prostitutes. In particular during the onset of the epidemic, unprotected sexual activity, especially homosexual activity, was identified as the pr imary culprit in HIV transmission in the United States. Researchers speculate that in itial HIV spread may have been linked to a Canadian homosexual flight attendant. Thus the role that population movement and behavior could play in the spread of HI V became a major focus of study. Subsequent research has shown how high rates of HIV in Afri ca are directly tied to the routes of truck drivers who were presumably soliciting prostitutes while ha uling their goods. Additionally, Paul Farmers (1992) dynamic publication, AIDS and Accusation implicates homosexual tourism as the main f actor responsible for the introduction of HIV from the United States to Haiti. Therefor e, population movement, including tourism, has long been associated with the spread of HI V and the growth in globalization poses and even greater threat to increasing the pandemic. Globalization refers to three distinct but interrelated and dynamic phenomena: increasing cross-border flows of goods, services, finance, people and ideas driven by t echnology changes and d ecreasing communication


2 costs; the opening of nati onal economies to such flows; and the development of international rules and the in stitutional architecture governin g these cross-border flows (Drager et al 2001). Globalization is a phenomenon that has contributed to the spread of HIV and STIs and has the poten tial to introduce the epidem ic to new populations at a rapid rate. This thesis is based on an internship experience undertaken from August 2003 to December 2003 through a grant awarded by the Globalization Research Center at the University of South Florida, to Dr. Nancy Romero-Daza. Since 2000, the University of South Florida in conjunction with the Univ ersity of Illinois at Chicago and Mount Holyoke College has run a six-week Globaliz ation and Community Health Field School in the Monteverde region of Costa Rica. This field school is designed to train students in qualitative and quantitative re search methods in community health. The Monteverde Institute, a nonprofit institution, hosts the field school every summer. In 2000 and 2001, meetings were held with community members to identify the health issues of utmost importance to the community. These issues ha ve been addressed through the field school research component and through independent projects. Community members identified HIV and other Sexually Transmitted Infections (STIs) as a growing concern. In 2002 and 2003, students from the field school undertook preliminary studies exploring HIV/AIDS knowledge and attitudes in the area. The c ontinual interest of community members in examining HIV/AIDS suggested the need fo r a more in-depth study with a special emphasis on the impact of touris m on local risk behavior. Romero-Daza, one of the field school dir ectors, developed an exploratory pilot study to assess the community pe rceptions of the potential impact tourism may have on


3 the spread of STIs, including HIV/AIDS, in the rural mountain town of Monteverde, Costa Rica. The project had five main objectives: (1) to understand the general characteristics and changing natu re of tourism in Monteverde (2) to assess the perspective of different segments of the local population about the potential role of tourism in the spread of STIs, (3) to assess tourists perceptio ns of HIV risk especially associated with changing behavior while on vacation, (4) to understand the level of knowledge and community satisfaction with existing educat ion and prevention activ ities, and (5) to identify new strategies for educating a nd disseminating information about STIs. Using a political economy and critical medical anthropology framework, the project focused on the ways in which increa sing globalization can affect the health of Costa Ricas population. Data were collected from various sectors of the population using a multiplicity of tools including in-depth interviews, surveys, focus groups, and observations. However, the data presented in this thesis are limited to focus group discussions, observations, and educational activ ities and discussions, which took place in several of the local schools. This thesis also reports on a public health education campaign that was designed and run the fi rst week of December 2003 in commemoration of World AIDS Day. While this thesis coul d be considered a nested qualitative study, on occasion, reference will be made to the overall general study. Because there had been little research done on STIs/HIV in the area, this project was mainly exploratory and will provide the basis for future interventions. The Situation in Costa Rica The Republic of Costa Rica is locate d in Central Ameri ca nestled between Nicaragua to the north and Panama to the s outh. Both the Pacific and Atlantic oceans


Figure 1. Map of Costa Rica flank the country offering two distinct coastlines. Costa Rica is a small country encompassing approximately 19,000 square miles with a population of close to 4 million people. San Jose is the capital city with close to 2.1 million residents. Spanish is the official language; however, English is spoken in many areas. The majority of Costa Rica is Roman Catholic (76%) with other religions growing; especially Evangelical churches (14%) (CIA 2005a). Costa Ricas most violent *Map taken from period was the Civil War in 1949. However, because of this war one of Costa Ricas most influential political leaders Jose Figueres Ferrer emerged to establish a strong democracy and initiate social reforms. Ferrer served three terms as president (1948-1949, 1953-1958, and 1970-1974). He is credited with re-introducing democracy, creating equality in terms of voting rights for women and blacks, extensive social reforms, developing the Pan American Highway, nationalizing the banking system, creating the National Institute of Housing and Urbanism, and abolishing the army in 1949. These radical reforms are attributed to todays relatively stable economic and political situation, which promoted the growth and development of the middle class. The middle class was only able to flourish because Ferrer freed up money and resources through these policies and focused them on developing a more 4


5 inclusive health care system, better soci al services, and strong public education programs. Costa Ricas economy is one of stronges t in the Central American region. The average per capita income as of 2003 was $4,193 with an unemployment rate of 6.7% (CIA 2005a). Tourism accounts for 21.3% of Costa Ricas GDP, which is second just behind industry (which includes food proces sing, textiles, and cement) accounting for 22.4% of the Gross Domestic Product (GDP) (CIA 2005a). Agriculture, once the main economic activity, now accounts for only 10.1% of the GDP (CIA 2005a). HIV in Costa Rica Although HIV/AIDS has not reached ep idemic proportions in Costa Rica, it nevertheless poses a major public health con cern. As of the end of 2003, rates of HIV infection were estimated at 0.6%, with a cumulative 12,000 people infected (including 4,000 women and 320 children), and 900 AIDS -related deaths during 2003 alone (UNAIDS 2004a). Given that the main route of transmission is changing from homosexual sex to heterosexua l sex, all segments of the population are at risk of infection. However, teenagers and young adults appear to be especially vulnerable. HIV and Young People in Costa Rica At present those between 15 and 24 year s of age account for over 10% of the total infections in Costa Ri ca (UNAIDS 2002a). Research in dicates that, while the rates of premarital sex are reported to be on the increase among young people, as a group they exhibit considerably lower le vels of knowledge about HIV transmission and prevention than older adults (Schifter a nd Madrigal 2000). Schifter and Madrigals (2000) study of HIV in Costa Rica revealed that many young Costa Ricans are engaging in unprotected


6 sexual activity. For example, 18% of unwed mothers are 19 years of age or younger and half of all pregnancies are unwanted (Schifter and Madrig al 2000). Only 13% of men and 18% of women report using contraception du ring their first sexual experience. This is particularly disturbing as a womans firs t sexual contact ofte n involves tearing and bleeding which increases exposure to STI/HI V. Education about HIV and STDs is limited among Costa Ricas youth. In a survey on AIDS in Costa Rica, nearly half of males (ages 15-24) said they received the majority of their sex education on the street (Schifter and Madrigal 2000) Moreover, 44% of females were not aware that correct condom use could reduce the rate of HIV transmission. Population reports (2001) on sexual activity among men in Costa Rica show that 42% of men 15-19 and 76% of men 20-24 report premarital sex. Costa Rica continues to have culturally rooted gender roles, which can partially be described as machismo and may place young people at an increased risk of transmitting HIV. Machismo is the pervasive at titude that males are expected to begin sexual activity early in adolescents, and to ha ve multiple sexual partners both before and after marriage, while females are expected to refrain from sexual activity prior to marriage. Within the system of machismo, wo men exercise few if any rights in relations to male sexual expression, while men exerci se almost absolute power in controlling womens sexual behavior (Parker 1996:62). HIV Prevention The Roman Catholic Church has stro ngly opposed efforts by the Costa Rican Ministry of Public Health to develop a nd implement HIV prevention and sex education programs (Van der Linde 2001). The Church deemed the condom campaign to be


7 immoral (Schifter and Madrigal 2000:2) be cause Catholicism supports the ideology of abstaining from any premarital sexual relati ons. The Church believes that married couples bear no risk of contracting an STI b ecause adultery is strictly prohibited (and therefore believed to occur rarely, if ever among practicing Catholics). Promotion of a condom distribution program, or sex education for that matter, would be conflicting with Church doctrine and in turn Divine Rule. However, statistical information concerning the onset of sexual activity and the context under which it occurs, conflicts greatly with the ideas of the Church. The Church ha s been highly successful in impeding these strategies and today sex edu cation is not compulsory in Costa Rican secondary schools, and its presence in the curriculum depe nds upon individual schools and teachers (Schifter and Madrigal 2000: 10; Van der Linde 2001). This suggests a crucial direction in which the Ministries of Public Health and the Catholic Church should be moving to prevent a catastrophic pandemi c from eliminating the mo st productive and vibrant segment of the population. The danger of asserting abstinence as the only HIV prevention message is demonstrated by current and past trends For example, approximately half of the 333 million new cas es of STDs are in young people less than 25 years of age (Mendoza 1998). Despite the growing numbers of HIV infected persons in Costa Rica, the Ministry of Public Health has done relatively little to combat this potentially devastating pandemic. Tourism and Sex Tourism in Costa Rica From 2003 to 2004, Costa Rica experienced an urban annual growth rate of 2.82 percent compared to a rural gr owth rate of only .57 percen t (UNPD 2004). Much of this migration is attributed to the growing tourism economy, which is Costa Ricas number


8 one commodity. Costa Ricas at tractive ecotourism industry resu lted in an 11% increase in international arrivals in 2003 with an estimated total of 1,239,000 tourists (World Tourism Organization 2005). An estimated 600,000 Americans visit Costa Rica yearly and upwards of 20,000 U.S. citizens now cons ider Costa Rica their primary place of residence (CIA 2005a). Costa Rica is attractive to tourists because of its biodiversity (25 National Parks and 8 Biological Reserves) with an abundance of varied flora and fauna as well as its stable democracy and overall lo w crime rate. Costa Rica offers access to both the Pacific and Caribbean coasts with numerous beaches for surfing, sailing, diving, fishing, windsurfing, and relaxing. There are also eight activ e volcanoes, and the jungles boast numerous species of birds, butterfli es, orchids, and mammals. Moreover, the adventure industry is growing rapidly with whitewater raftin g, kayaking, zip lines in the rainforest, horseback riding, bungee jumpi ng, mountain biking, and sport fishing booming. A tourist can engage in numerous activities and adventures within a short plane ride from the United States, and at very economical prices. In the developing world, a shift from rural regions to the urban and tourist meccas is a trend fueled by globalization and world market systems in conjunction with images of western lifestyles and commodities (Forsythe et al. 1998). Today there are a growing number of young people seeking job opportunities in urban and tourist meccas in hopes of economic gain not realizable in tr aditional agricultural lifestyles (Forsythe et al. 1998). This population mobility within a country in conjunction with the movement of tourists has long been implicated in th e facilitation of HIV transmission through a proliferation of the commercial sex industr y (Farmer 1992) as well as the creation of illegal child trafficking (UNI CEF undated). Costa Rica has legal prostitution for those


over the age of 18 (U.S. Department of State 2004a) and promotes commercial sex to tourists through various web pages that detail access to massage parlors, steam baths, escort services, and nightclubs. Prostitution is evident in the capital city as well as in major tourist centers especially in beach communities. One taxi driver explained to a reporter from the British Broadcasting Company (BBC), When tourists arrive from other countries and get into my taxi, the first question they ask is, 'Where are the girls? Where are the little girls? (Wright 2004). Costa Rica is considered a destination and transit country for children and women trafficked from Colombia, Dominican, Republic, Eastern Europe, and Nicaragua (U.S. State Department 2004b). Costa Rica has recognized the problem of child prostitution and initiated legislation to punish offenders, who may serve up to 10 years in prison if convicted of having sex with a minor (U.S. Department of State 2004a). 9 Figure 2. View from Monteverde Sex tourism is on the rise due to a significant portion of the population (18%) living in poverty (CIA 2005a). The greater the poverty level is in a country, the bigger the workforce available for the commercial sex industry. The situation in Costa Rica is compounded by high rates of poverty in neighboring countries. In Nicaragua, 50% of the population is living in poverty (CIA 2005b) and in Guatemala, 75% (CIA 2005c). Out of desperation, many women and children


migrate to Costa Rica in search of work, which often ends in prostitution or some other form of exploitation. Study Site: Monteverde, Costa Rica Monteverde is a rural area in the Tilaran mountain range in the northwestern highlands of the Puntarenas province 167 kilometers from San Jose, the capital city. Santa Elena is considered the heart of Monteverde and the most popular tourist destination in the region. Santa Elena is located at 1300-1400 meters above sea level and has an estimated population of 6,000 permanent residents. It was originally an agricultural and dairy farming community with an emphasis on coffee. However, today tourism has superseded agriculture as the number one economic activity in the area. 10 Figure 3. View of Santa Elena Quakers from the United States settled in the area during the 1950s, leaving the States as conscientious objectors to legislation that initiat ed the draft of the Korean War. They were attracted to Costa Rica because there was no national army (Mader 1990). With their settlement, 3000 acres, dairy farming and cheese production was introduced into the area. The Quakers also bought a large section of rainforest in an effort to protect the watershed. Much of this land is now part of the Monteverde Reserve. The reserve encompasses 10,400 hectares and is one of just 12 rainforests left in the world where there is still primary forest: trees


that have never been cut (Monohan 2004: np). A definite rainy season begins in May and lasts until October dumping upwards of 100 inches of rain. The dry season lasts from January to April and coincides with the high season of tourism Monteverde is characterized by its biodiversity with estimates of over 400 bird species (among these 30 types of hummingbirds) including the resplendent quetzal, 2,500 plant species (420 types of orchids), and over 100 mammal species. 11 Figure 4. Sunset View from Monteverde Today the primary industry is tourism with visitors traveling to the area for a variety of activities including bird watching, hiking, horseback riding, canopy tours, butterfly gardens, and RV rentals. An estimated 250,000 people visit Monteverde annually (Monohan 2004). Because of the bombing tourist industry there is a constant influx of young people from different parts of the country looking for work opportunities. Santa Elena is a rather small community with only one major supermarket and bank. There are a numerous restaurants around the town center, which serve a variety of foods. There are also several tourists shops, which sell Costa Rican grown coffee and foods along with other mementos and souvenirs. The Catholic Church is located in the middle of the town square with an adjacent community-meeting hall. Several small hotels in the center tend to cater to the backpacking crowd. One main bar, mainly frequented by locals, is in the town center with the tourist bar just up the road toward the reserve area. In addition,


12 there is a large soccer field and basketba ll court on the outskirts of town. The one public health center a government clinic, is located up the road from the field and serves Monteverde and the sm aller surrounding communities. There are various smaller private practices in the area as well as a few dentists. However, the majority of locals seem to frequent the pub lic clinic. In addition, there are several schools in the area, both private and public. It is important to note that the area of Santa Elena and Monteverde is growi ng rapidly due to the influx of tourists and capital into the area. Therefore, it is not surprising to see many new facilities under construction and certain to change the face of the community in radical ways.


13 Chapter 2: Literature Review Applied Medical Anthropology and HIV Research Medical anthropology, a subfield of cultural anthropology, has been defined as an academic discipline devoted to a comprehensive, cross-cultural, systematic understanding of human health, illness, illness prevention, a nd curing. Its major focus of interest and analysis is health-related knowledge, beliefs, practices in medical systems of both nonWestern and westernized, industrialized societies (Gwynne 2003:248). There has been a movement in anthropology away from simp ly studying and analyzi ng culture to using these data in an effort to ch ange or solve human problems. This shift within the field of simply gaining knowledge to using that know ledge in a pragmatic, problem-solving way led to the development of applied medica l anthropology. Some argue that medical anthropology by its very natu re is applied as all resear ch in medical anthropology has direct or indirect applicati ons to human health and medici ne (Whiteford and Bennett in press) Therefore, some researchers tr ace the earliest roots of applied medical anthropology back to the early 1900s when social observers, including physicians, examined the behaviors and ideologies of di fferent cultural groups throughout Africa and in the New World. For example, these early observations led one anthropologist/physician to in corporate a new understanding of stress and anxiety into medicine through his identification of what is today referred to as Post Traumatic Stress Disorder about World War I soldiers (Whiteford and Bennett in press).


14 Gwynne (2003) defines applied medical an thropology as the use of theories, methods, and accumulated data of medical anthropology to address specific healthrelated problems and achieve specific, pr actical, health-related goals (2003: 249). Joralemon (1999) explains three characteristic s of medical anthropology that make it an effective science able to study, understa nd, and promote health within and among different cultures. First, medical anthropology utilizes a wider temporal and geographic scope than other social sciences. Therefore, medical anthropologists are able to examine the variety of global forces, especially econom ic and political struct ures that influence health patterns in local communities. Fo r example, many scholars now recognize the impact of capitalism on health (Farme r 1992, 1996, 1999, 2003; Romero-Daza and Himmelgreen 1998; Singer 1989, 1990, 1994, 1998). Economic inequality is a natural extension of global markets re sulting in a wide gap between the health outcomes of the poor and the rich. Medical anthropology exam ines these health outcomes within the context of a particular commun itys ties to the global market system. Secondly, medical anthropology considers both cultural and biol ogical patterns of disease (Joralemon 1999). This biocultural perspective allows researcher s to understand the cultural context within which biological disease and illness manifest themselves. Whiteford and Bennett (in press) explain that the biol ogical synthesis refers to the ability of medical anthropology to think about the ways in which cultural rules about disease r ecognition and treatment intersect with germ pathology of disease. Th is understanding is par ticularly useful for developing illness prevention and education programs. For example, Whiteford and Bennett (in press) demonstrat ed the effectiveness of implementing a Community Participatory Intervention (C PI) Model to prevent the sp read of Cholera in rural


15 Ecuador. This project was successful because researchers incorporated local ideas about risk, disease, and behaviors while encouraging community leaders to direct and implement prevention and education in the region. There were 25,547 fewer cases of cholera after one year following the initiati on of the CPI model. Finally, anthropology brings a research strategy that involves multiple qualitative and quantitative methods (Joralemon 1999) such as informal and form al interviews, focus groups, participant observations, life histories, and surveys. Th is approach allows for a more in-depth, holistic understanding of the cultural, ecol ogical, and biological environment within which illness occurs. Applied medical anthropology is particular ly useful in understanding and preventing HIV/AIDS. HIV/AIDS is spread through di rect contact with in fected blood and body fluids. Possible routes of transmission include unprotected sexual contact with an infected person, infected blood transfusions, sharing infected syringes and needle stick injuries, and vertical transmission from an in fected mother to her baby (CDC 2003). HIV transmission patterns va ry among different cultures and populations. For this reason, HIV prevention is particularly chal lenging. For example, in Brazil HIV transmission is most common among Inje ction Drug Users (IDUs) and homosexuals; however, heterosexual transm ission is now on the rise (UNAIDS 2004b). In the U.S., men who have sex with men (MSM) and ethni c minorities have the highest rates of HIV transmission but rising rates among women and especially minorities are occurring (CDC 2005b). In Costa Rica, the epidemic began am ong men who have sex with men with over half of AIDS cases between 1998-2002 among MSMs (UNAIDS 2004a). However, today, there is an increase in heterosexual transmission. This trend may be a result of


16 contact with tourists and MSMs who are bi sexual. The difficulty in controlling HIV results from the diversity of circumstances and environments within which it spreads. However, the majority of transmission is th e direct result of hu man behavior and the ability or inability to make decisions to prot ect against the disease (there is very limited transmission of HIV from bl ood transfusions). Anthropology examines these varied settings and different mechanisms at work driving human behavior and decision-making. With its unique focus on studying human behavior through an examination of individual cognition as well as the relati onship of a community to larg er macrolevel processes, anthropology can inform theory about human behavior and risk-taking, and can contribute to the development of cultura l relevant and efficacious prevention and education programs in diverse settings Anthropology and HIV Research Anthropologists offer an alternative to biomedical prevention by examining the multiplicity of factors that lead to risk behavior and addressing these underlying cultural constructions as well as the global forces that lead to risky sexual behavior. Anthropological research on HIV transmission and prevention is prolific in both the U.S. and abroad. Re searchers in the U.S. have focused studies primarily on populations identified as hi gh risk including: injection drug users, minorities, sex workers, and men who have sex with men (MSM) Whereas those studying HIV in developing countries face a very different epidemic whereby entire communities, and not simply subpopul ations, are infected. Both groups of researchers examine HIV within the contex t of larger political, economic, social, and historical forces.


17 Injection Drug Users Injection drug use is defined as any action that manipulates a syringe to inject drugs into the body and is not limited to those who inject only into veins. Injection drug use continues to be a major source of newly acquired HIV infections in numerous countries. For example, in some parts of Br azil there is a prevalen ce rate of 42% among Injection Drug Users (IDUs) (UNAIDS 2003). There is growing concern of the increasing rates of HIV among IDUs in Asia Chinas IDU population has an estimated prevalence rate of 40% (UNAIDS 2003). Vietnam and Thailand report 80% and 85% HIV prevalence rates, respectively (UNAIDS 2003). The Ukraine reports the highest HIV prevalence rate among IDUs in all of Europe at 74% (UNAIDS 2003). In the United States, the Centers for Disease Cont rol (CDC) reports that of the 42,156 new cases of HIV identified in 2000, 28% were associated with I DUs (CDC 2002). The work of anthropologists such as Romero-Daza and colleagues (1999, 2003, 2005), Himmelgreen and Singer (1998), Singer (Singer et al 1995), Weeks (Weeks et al 2002), Trotter (1995, 2000) and Bourgois (1998, 1999) has been instrumental in providing insight into the multiplicity of variables in cluding poverty, street violence, domestic and international forces, and involvement in social networks which coalesce to result in high risk behaviors among IDUs. In an effort to design and implemen t effective HIV education programs among IDUs it is important to understand both the mi cro and macro-level environments within which IDUs function and the impact these forces have on thei r individual decisionmaking and behavioral patterns. IDUs are at risk for infection when they expose themselves to the virus through infected bl ood or other body fluids. The appearance of


18 shooting galleries, where drug users meet to inject drugs togeth er, correlates with increased rates of HIV transmission among IDUs (Bourgois and Bruneau 1999). In these galleries, IDUs often share needles and other pa raphernalia, such as cookers, wash waters and cottons (pieces of cotton used to trap dr ug particles that do not dissolve) that are capable of transmitting HIV, among other blood borne infections (Bourgois 1998; Koester et al 2005; McCoy et al 1996, Riehman 1996). Unders tanding the variety of reasons that lead IDUs to share needles can be difficult. This makes ethnography an indispensable methodological technique. IDUs report needle sharing because they do no have access to clean syringes or materials for sterilizing their equipment (Bourgois 1998). In many instances, IDUs report fear of being caught with syringes because in many states it is illegal to carry drug para phernalia. Therefore, there is a scarcity of needles resulting in risky sharing behavior (Carlson et al 1996; Koester 1994). Some IDUs may believe sharing is safe because they do not feel the others they are injecting with are infected or they are simply too high to think about the consequences (Bourgois and Bruneau 1999). In addition, IDUs report shari ng paraphernalia and needles when they jointly purchase drugs, and therefore inject with each other (Koester et al 2005). There are even scenarios whereby individuals share needles out of a se nse of camaraderie and view drug injecting as a social activity (Koester el al 2005), although this has been disputed because it can be seen as victim blaming. Anthropological research has focu sed on understanding the specific social networks, both personal and larger structural networks, within which IDUs participate (Singer et al 1995, Weeks et al 2002). IDUs are at a par ticularly high risk of HIV transmission because of the heterogeneity of their different social networks. This


19 heterogeneity makes it difficult for pubic hea lth officials and community health workers to reach at risk groups with general HIV prev ention materials. For example, Weeks and colleagues (2002) analysis of high-risk sites concludes that there are different ethnic and economic micro-networks of drug users, but that there are bridgi ng links which bind these peripheral networks together into a larger macrolevel network. The authors surmise that by identifying individuals who are strategically located within the macrolevel networks and training them with cultura lly relevant prevention information, there is a greater possibility of reaching a wider range of individua ls. A more focused, culturally relevant approach needs to be undertake n. Ethnographic research methods allow researchers to understand the clients point of view, their understa nding of events and behaviors, and the meanings they derive from them, as well as indigenous knowledge, values, and past experiences (Singer et al 1995: 247) which impact the efficacy of intervention and prevention programs such as Needle Exchange Programs. Sterk and Elifson (1999) support the conclusion that th ere are select influential individuals within drug using social netw orks. Their research shows how central individuals are able to influe nce others within the social network from switching from heroin injection to heroin smoking. As Weeks and colleagues state (2002: 203), With knowledge of social ties and structural li nkages among drug users and their contacts, we can begin to move beyond indi vidual-centered, behaviorist explanations of HIV risk, transmission, prevalence, and formulas for pr evention. Trotters research (Trotter and Mora 2000) further emphasizes the importa nce of understanding complex social networks. His research demonstrates that i ndividuals assess the impact their behaviors have on their social network. These data suggest that by being armed with this


20 information public health and community he alth programs can bette r devise effective HIV prevention programs. It is important to note that labeling an individual IDU may re sult in ineffective HIV education because general public health programs assume homogeneity within this risk category (Singer et al 1998). Therefore, not educ ating about other routes of transmission or addressing other structural determinants may result in a lack of attention being given to possible alternative risk fact ors such as violence, lack of education, poverty and prostitution faced by IDUs. For example, Gorman and colleagues (1997) reveals the importance of addressing the dual risk faced by IDUs who are also gay men (DU-IDU), especially those w ho frequent party circuits, with targeted and culturally appropriate prevention and h ealth care services. Singer and Romero-Daza (1999) introduced the concept of the SAVA syndemic which is an acronym for substance abuse, vi olence, and AIDS and suggests a relationship between these variables that directly affect women, partic ularly those engaged in sex work in the inner-city (Rom ero-Daza et al 2003, 2005; Singe r and Romero-Daza 1999). Many women are involved in sex work because of a drug addiction and face violence daily, for these women it is n ecessary to break the vicious cycle of violence, drugs, and prostitution that is perpetuate d by the oppressive social, economi c, and political reality of the inner city (Romero-Daza et al 1999: 255). Sex Workers and HIV Prostitutes, female prostitutes in particular, are often seen as vectors of disease transmission and not as victims of larger structural flaws. However, anthropological research has contributed to the understanding that prostitutio n is often the result of


21 structural barriers that prevent both men a nd women from providing for themselves and their families (Farmer 1992, 1996, 1999, 2003; Kreniske 1997; Romero-Daza et al 1999, 2003). Research has identified women as particularly vulnera ble to relying on prostitution as their only means of economic survival because of gender inequality causing limited education, joble ssness, submission to males or household breadwinners, and limited access to health care (Farmer 1996). In reality, anthropologists maintain that women are more likely to become infected th an they are of inf ecting others (Farmer 1996; Schoepf 1991). Several resear chers identify inequality as a cofactor in infection. Research has identified variables th at lead women, men, and children to prostitution for economic survival including racism, sexism, political violence, drug addiction, and poverty (Farmer 1996; Romero-Daza et al 1999, 2003, 2005). Moreover, sex work results when there is a signif icant demand for such services. Common environments that encourage prostitution include development or construction projects that rely on cheap, migrant laborers (whereby workers are separated from their families), free trade, or industrial zones, areas with large numbers of milita ry personnel, urban centers that traditionally have a large gap between the rich and poor, and tourist areas. For example, in the case of the Dominican Republic research shows low incomes and unemployment coupled with inflat ion particularly of the pri ces of essential itemsserve as strong motivators for sex work (Kreniske 1997:36). In Haiti, Farmer (1992) examines how the corrupt political system in conjunction with a fledging economy resulted in a large, extremely poor lower class. He then concludes that inequitable power and economic distribution results in the poor being forced into occupations (the sex


22 industry) to serve the desire s of a powerful elite (tra veling westerners or local aristocracy). Women working as prostitutes are particul arly vulnerable to HIV for numerous reasons. For example, women are often expos ed to other sexually transmitted infections (STIs) because of their high levels of sexual contact with multiple partners. HIV transmission is facilitated by the presence of other STIs, which are common among prostitutes (Asthana and Oostvogels 1996; UNAIDS 2002). In addition, research has shown that sex workers are particularly vulnerable to violence, and therefore HIV transmission, while working as prostitutes (Romero-Daza, et al 1999, 2003, 2005). Violence, such as rape, physical abuse, and sexual abuse, are often commonplace and considered occupational hazards which place both women and men at an increased risk for HIV infection (Jackson et al 2001, Romero-Daza et al 1999, 2003, 2005). Moreover, many clients will pay prostitutes more money to have sex without a condom. Unfortunately, many of these women comply with their requests b ecause poverty is the motivating factor for them being involved in prostitution (Jackson et al 2001, Karim et al 2001). Women report being afraid to negotiate for condom use because they fear violence or abuse by their clients if they suggest using protection (Karim et al 1995; UNAIDS 2002). Unfortunately, there has been little research done on the perspectives and motivations of commercial sex clients. Because of the nature of their activities, many clients prefer hiding their identities and are not accessible to researchers (EsuWilliams 1995). The spread of HIV has been linked to prostitution and migr ation throughout the world since the beginning of th e epidemic. For example, the original outbreaks of HIV in


23 Africa occurred via heterosexual transmissi on along long haul truck driver routes whereby truckers visit prostitutes on their journey (King 2002; Schoepf 1991). The phenomenon of rural-to-urban to rural mi gration among those working as prostitutes needs to be addressed as a factor increasing the risk of HIV transmission. Research documents women working in tourist areas in Thailand and the Dominican Republic as being part of this migratory pattern in search of occupa tional opportunities (SinghanetraRenard 1997; Skoczen 2001). Women and men who migrate to tourist areas working in prostitution often have regular partners in their rural hometowns. When these sex workers become ill, often with STIs and/or HIV, they often return home to recover. It is common for sex workers to have unprotected sex with their regular partners while at home (Jackson et al 2001, Karim et al 1995; Skoczen 2001). Both women and their intimate, steady partners prefer to have se x without using a condom because it separates their occupation from their personal lives and women repor t feeling more emotionally attached to their partners which is why they tend to not use condoms (Jackson et al 2001, Karim et al 1995; Kerrigan et al 2001). This has been identi fied as a common route of transmission and one that is rarely addr essed by education and prevention programs (Jackson et al 2001; Karim et al 1995; Kreniske 1997). Research examining male prostitution and the transmission of HIV are less extensive despite the high rates of HIV repor ted among this population. For example, in 1993 rates were as high as 29.4% in one study population of male prostitutes (Elifson et al 1993). Because of the biological nature of same sex intercourse between men, which often entails a high rate of blood and semen exchange during anal sex between partners, MSM are at high risk of infection (Elifson et al 1993). Anal sex, particularly for the


24 receiving participant, often results in some tearing of the anus, which then becomes a vehicle for HIV transmission. Moreover, male prostitutes exhibit higher rates of STDs, which, especially if there are open sores, is associated with HIV transmission. There is research showing that males often enter into prostitution because of the need to support a drug habit. Male prostitutes who also inje ct drugs are particularly vulnerable to HIV because they expose themselves by multiple ro utes of transmission. Interestingly, men, like women, are at an increased risk of HIV transmission with non-paying partners because condom use is less common (Elifson et al 1993). In order to prevent HIV among sex worker s structural characteristics such as poverty, gender inequality, limited access to resources and education, and sexism, which force women into sex work, need to be addr essed. Researchers suggest increasing gender equality though advocacy, educat ion, legal rights, and equal opportunity as an essential first step (Farmer 1999, 2003; Romero-Daza et al 1999). In addition, health care systems must insure quality treatment and accessibility for sex workers including the treatment for both HIV and STDs (Farmer 1996:35). Univer sal HIV education and stigma reduction focusing on educating young people about th e connection between HIV, poverty, and gender inequality must be undertaken (Farmer 1996). Support services for sex workers must include the following components: self-esteem building, education to increase employment possibilities, empowerment, sex education, drug rehabilitation (when appropriate), and general h ealth education (Romero-Daza et al 1999). Moreover, women must be aware of the risk they face in their home lives when having unprotected sex with their signific ant others.


25 Education and prevention must not simply target sex workers, but their clients as well. Mandating condom use th roughout the legal commercial sex industry has proven effective in places such as Thailand and the Dominican Republic should be expanded, especially with the growth in sex tourism (Kerrigan et al 2001; UNAIDS 2000). Trafficking for Sexual Exploitation Child trafficking refers to the moveme nt of children that is inextricably associated with their subsequent exploitation by others in a way that violates their human rights usually by being forced to make m oney for them by working, but in the case of babies who are trafficked for adoption a nd young women trafficked for marriage, to satisfy the demands of those who take cont rol of them in other ways (Dottridge 2004:17). Child trafficking is illegal w ith underground networks shuffling children within and between countries, because of the secretive nature of the business it has been difficult to estimate the total number of child working in the commercial sexual exploitation industry. The International Labor Organization estimate of 1.8 million trafficked children in 2000 might be a conservative figure (D ottridge 2004). Women and children who are trafficked ofte n find themselves forcibly working as domestic servants or in various industries because they are sources of cheap labor. Others find themselves in forced marriage ar rangements or working as sex slaves. The widespread use of the internet advertisements geared toward sex tourists, and increasing child pornography have all been implicated in expanding the market for child prostitution (UNICEF undated). Child trafficking and prostitution is a growing phenomenon particularly in areas of heavy tourism activ ity. For example, in Mexico there are an estimated 16,000 children working as prostitu tes predominantly in the tourist sector


26 (UNICEF undated). Women are often deceived by false promises of better job and educational opportunities. Children may be a bducted, sold by poor parents, or their parents deceived by false promises of a better life for their children in a new country. Traffickers use coercive tactics includi ng deception, fraud, intimidation, isolation, threat, and use of physical force, and/or debt bondage to control th eir victims (Human Rights Watch 2004). Researchers have also found many children, espe cially orphans and street children, engage in survival sex (Loc khart 2002). Street child ren in Tanzania are forced into street sex because of dire econom ic and social conditions as well as the need to maintain some sort of hierarchy of power and authority characterizing their relationships with one another (Lockhart 2002). HIV/AIDS is not just a result of child expl oitation, but also a ca use. Children are particularly vulnerable to expl oitation when they are orphaned by both parents, which are becoming more prevalent due to the HIV/ AIDS pandemic. Children and women are susceptible to becoming victims of this same pandemic because the sexually exploited are at an increased risk for HIV transmission. Children are biologically susceptible to transmission, and both women and children are at an increased risk due to the violent nature of many of their forced sexual experiences. Moreover, with the growing HIV/AIDS epidemic, male clients of commerc ial sex workers are beginning to show a preference for younger sex workers because they believe there will be a smaller chance of him/her being HIV positive (Dottridge 2004). In some cultures, there is still the insidious mentality that sex with a virgin will cu re HIV/AIDS (Amnesty International 2005; UNAIDS 2002; Dottridge 2004) which increases the demand for child sex workers.


27 Trafficking of women and children is not only illegal, but also an outright violation of basic human rights. Unfortunate ly, there is not an easy solution because the problem is rooted in larger, structural flaw s that force women and children into desperate situations because of larger inequalities and discrimina tion. Women and children are vulnerable to trafficking because they of ten are not awarded any form of selfdetermination and suffer from a lack of e ducation, minimal resources, and no power or voice. As Farmer explains, civil rights canno t really be defended if social and economic rights are not (1999:9). Men Who Have Sex with Men (MSM) Men who have sex with men (MSM) in the United States continue to account for the highest number of new HIV infections each year. The CDC reports that in 2000, there were 13,562 AIDS cases among MSM (CDC 2002a). In the U.S., HIV was discovered in the gay population living in Calif ornia and was quickly attributed to high rates of casual sex with multiple, often anonym ous, partners in notorious bathhouses. In fact, HIV was originally termed GRID, Ga y Related Immune Deficiency until the virus was found to have contaminated the blood suppl y and infecting people who were not part of the homosexual community. However, the MSM community continues to be the hardest hit by the epidemic and despite decr easing rates over the past few years, there seems to be a shift in the mentality of young MSM, which is resulting in a reemergence of HIV and STIs (Ekstrand et al 1999; Rofes 1998; Sheon and Crosby 2004). Many homosexual men, especially following the emergence of HIV, do consider themselves part of a larger unified, homosexua l community. However, it is important to note that MSM do not constitute a homogenous community or group. There are a


28 significant number of individuals who self-i dentify with different social and cultural groups or communities and would not consider their activities homosexual in nature. For example, some men, especially Latino men, mask their homos exual activities because it is not acceptable in their communities that promote macho attitudes; therefore, many fear discrimination and stigmatization or cognitively do not view their behavior as homosexual in nature (WHO 2000). Some men who only penetrate their partners and are not receptive during anal or or al sex may also not identify as homosexual (Asthana and Oostvogels 2000). Men who are substance abuser s may sell sex in order to make money to supply their habits. These men may not consider themselves homosexual either. Many of these men are often bisexual and pos e a particular risk for HIV transmission because they hide their activities and are difficult to reach with HIV/STI prevention materials. Moreover, some of these men might maintain regular sexual relationships with wives, girlfriends, or others who are unaware of their ac tivities, which places their partners at an increased risk of contracting HIV (Andalo 2003). Individuals who do self-ide ntify as homosexual and are active in the homosexual community are facing a different epidemic today than those members who were active during the initial outbreaks. Researcher s have identified ne w attitudes emerging, especially among younger members of the ga y community, following the initiation of HAART (highly active antiretroviral therap y) in 1996 (Rofes 1998). The original frenzied attitudes surrounding the AIDS crisis have diminished as more and more HIV positive men are surviving and even thriving with the help of protease inhibitors. Today, HIV is not the death sentence it was in the past Rofes (1998) explains that as the number of obituaries of AIDS victims decrease, AIDS hospices close, and fewer visual signs of


29 the disease are seen, the idea of crisis diminishes. Attitudes are becoming more lax or outright ambivalent concerning HIV in some segments of this population, which has resulted in increasing rates of HIV a nd STI transmission among young MSM (Sheon and Crosby 2004). Another contributing factor to the rise in HIV rates is the attitude by HIV negative gay men that they are somehow isolated from the gay community simply by their seronegative status. Some men report feeling less gay when they cannot participate in discussions about HIV medica tions or health issues (Sheon and Crosby 2004). In some segments of the gay community, the idea of havi ng to maintain safe sex practices for the rest of their lives is overw helming, disheartening, and exhausting and therefore some men engage in barebacking. Bareb acking is the slang term used to describe sex that occurs without the protection provided by a condom and is usually a term reserved for reference to anal intercourse between gay men (Gau thier and Forsyth 1999:86). Moreover, there is a new phenomenon within the younger, gay community that has been facilitated by the widespread use of the internet and is referred too as bug chasing. Bug chasing is the term used to refer to the act of bareback ing when the particip ants include both HIVpositive and HIV-negative gay men, and the la tter is knowingly seek ing infection from the former (Gauthier and Forsyth 1999:86). Gautier and Forsyth (1999) identify other major reasons why some HIV negative men actively seek to seroconvert and include not wanting to live in fear of conversion, beco ming positive will provide some relief, risk taking is exotic, wanting a sense of group solidarity and comm unity, and rebelling against homophobic culture. These feelings coupled with the attitude that HIV seroconversion is inevitable lead to increased HIV risk taking behaviors.


30 Minorities The CDC reports that in 2003, 31% of reported AIDS cases were among Caucasians, 48% among African Americans, and 18% among Latinos (2003). African Americans are the hardest hit with an es timated 368,169 AIDS cases, which accounts for 40% of all cases, since the onset of the ep idemic (CDC 2005c). Latinos represent the second highest rate of HIV diagnoses for all racial and ethnic groups (CDC 2005b). Latinos accounted for 20% of AIDS cases among adults and adolescents in 2003, and African Americans accounted for 42% (CDC 2005c). The CDC is careful to report, race and ethnicity are not, by themselves, risk factors for HIV infec tion (CDC 2005c). However, there are risk factors that are di sproportionately affecti ng these populations and placing them at a higher risk of HIV infection including: subs tance abuse in general, and injection drug use in particular; higher rates of sexually transmitted diseases especially gonorrhea or syphilis; higher levels of pove rty which limit access to healthcare, education, and prevention resources; and finally denial of homosexual or bisexual activities due to cultural constructions of gender roles that prohibit or stigmatize same sex relations. Despite these sim ilarities, researchers have also found profound differences between different ethnic populati ons that result in high-risk behavior. Anthropologists have undertaken in-depth studies in the U.S. among various populations, however, studies on Latino populations (Hirsch et al 2002) and among African American women (Sobo 1993, 1998) are some of the most comprehensive. Individual ethnic groups ha ve their own cultural constr uctions of marriage, love, sex, and intimacy. Therefore, understanding ri sk behavior must be placed within the


31 context of each individual cultural groups idea ls. Added to this complexity is the affect of globalization, which often separates families for extended periods as young people migrate to urban areas, often in other countri es, for jobs or other economic pursuits. A classic example is the influx of Mexican migrant workers who flood into the United States everyday. Many of these workers ar e young men who have left behind wives and girlfriends in Mexico. Because of the difficulty of the journey, and often high expenses of paying coyotes 1 to cross into the U.S., many migran t workers remain in the U.S. for extended periods. This isolation from their se xual partners places them at higher risk for contracting and transmitting HIV and other ST Ds. Hirsch and colleagues (2002) explain that Mexican migrants relative youth, their loneliness and social is olation, and the fact that many are single or traveling without th eir spouses may make them likely to seek sexual activity, and low levels of education and limited English may make it harder to reach these migrants with messages about HIV prevention (1229). Researchers also found that women in rural Mexico are not likely to require condom use when their partners return ignoring the possibility of infi delity in an effort to encourage the ideal of sexual intimacy and trust. Hirsch (2002) found that many women recognize the fact that men who travel for work are engaging in extr amarital activities, however, they maintain that their partner is the exception to the ru le. Finally, there is the age-old complaint that sex with a condom denies tr ust and is less pleasurable. Sobo (1993) found that African American inner-city women held similar ideals as their ethnic minority counterparts about th e ideal of monogamy a nd not the reality of men having multiple partners or engaging in unsafe high-risk activities. Women who 1 Coyote is slang for a paid guide who smuggle illegal Mexican immigrants into th e U.S. for a substantial fee, sometimes upwards of $1,000 depending on preferred destination in the U.S.


32 engage in sex with high risk partners are often opposed to wearing condoms because they feel it takes away from their intimate and trust relationship. Some impoverished women are economically dependent on their pa rtners and suggesting the use of a condom might threaten their financial resources. However, research ha s found that inner-city women tend to engage in unsafe sex for a pl ethora of other reas ons which are more dominant than the idea of financial dependenc y. In fact, Sobo points out those inner-city African American men are often an unstable source of money and resources because of high rates of unemployment, drug addiction, homicide and the greater likelihood of them being incarcerated. Therefore, inner-city wome n are often forced to be self-reliant. Sobo (1998) attempted to uncover th e other myriad of reasons women engage in unsafe sex. She discovered that women actively use unsaf e sex as part of a psycho-social strategy for building and preserving an image of th emselves as having achieved the conjugal ideal (Sobo 1998:79). Moreover, women are more dependent on men for self-esteem building and increasing status. Sobo conc luded that condomless sex among black women had more to do with love, not money and that it is more about a psychosocial connection. Preventing HIV transmission among ethnic minorities is a difficult task because accessing these populations can sometimes be a challenge due to language barriers, illegal immigrant status, and high levels of mobility. Additionally, many traditional education campaigns have focused on empowering women to negotiate for condom use. However, the larger structural barriers such as poverty and soci al inequality are not being addressed. Hirsch and colleagues (2002) maintain that to suggest that we can help married women protect themselves by empowering them to negotiate for condom use is


33 to suggest that we can change the outcom e of gendered inequali ties in power without doing anything about the actual inequality ( 1233). We are theref ore only placing a band aide on a much bigger problem. Whiteford and Vittuci (1997) claim that federal policy requiring drug tests for incarcera ted, pregnant women unfairly targets the marginalized and suggest that social values about sex, class, ethnicity be come institutionalized in law and medicine in ways that unfairly stig matize and jeopardize low-income women of color (1371). Such policy blames these women so we do not have to examine, criticize, and blame our own society. It is easier to pick on the vulnerable than to initiate policy and programs geared toward ending structur al violence. Clearl y, changes must be mandated at the policy level as well as in th e community. Finally, re search undertaken in the U.S. clearly demonstrates that strategies are ineffective when they do not address the psychosocial elements of risk behavior. Globalization and Tourism Globalization refers to th ree distinct but interrel ated and dynamic phenomena: increasing cross-border flows of goods, services, finance, people and ideas driven by technology changes and decreasing communi cation costs; the opening of national economies to such flows; and the development of international rules and the institutional architecture governing these cross-bo rder flows (Drager et al. 2001). These crossborder movements facilitate HIV and STI transmission. The 15 th century expeditions of Columbus to Haiti resulted in the transmission of syphilis from native women to sailors and subsequently from sailors throughout Eu rope thus documenting one of the earliest impacts of travel on STD transmission (Memish and Osoba 2003). Therefore, it is not surprising that HIV/STI transmission is incr easing along with globalization. Infectious


34 disease specialists are cognizant of the rapi d growth in internat ional tourism. For example, in 2003, there were 691 million in ternational traveler s (World Tourism Organization 2005). Central America played hos t to some 4.9 million of those travelers, which is an increase from the previous y ears estimate of 4.7 million (World Tourism Organization 2005). The Caribbean is now one of the most popular tourist destinations playing host to some 17.1 million visitors in 2003 (World Tourism Organization 2005). Tourists are attracted to cheap rates, all inclusive resorts, and beautiful sandy beaches. It is not a coincidence that the Caribbean also boasts the highest rate s of HIV outside of Africa (Skoczen 2001; UNAIDS 2005a) with a 2.3% adult prevalence rate (UNAIDS 2004b) the majority of which are spread through heterosexual transmission. There has been a proliferati on of sex tourism, especially with the explosion of the internet. Sex tourism is defined as traveling to a foreign country with the intent of paying for and engaging in any variety of sexual activities. In many countries, prostitution is legal and sex tourism is promoted in order to boost the economy. Countries such as Thailand, South Africa, Greece, Costa Rica, and Dominican Republic, all promote the development of their tourism industries, in cluding the promotion of sex tourism. Hannum (2002) suggests that th e explosion of sex tourism is primarily limited to developing countries because th ere is a readily available wo rkforce. Men and women in poorer countries are more likely to engage in sex for money because they have limited occupational opportunities. World Vision (2004) reports that sex tourists travel to countries such as Cambodia, Thailand, Co sta Rica, Mexico and Brazil, expecting anonymity, low-cost prostitution, easily ac cessible children and impunity from prosecution.


35 There are numerous studies, which examine the transmission of HIV from tourists to commercial sex workers (Forsythe et al 1998; Kerrigan et al 2001; and Skoczen 2001). It has been suggested that commercial se x workers are one avenue for the spread STIs/HIV into the interior or rural regions of these c ountries through unprotected sexual activity with regular partners or close relations hips located away from the service sector. Therefore, it is not surprising that HIV rates are now escalating in once untouched areas. However, little has been done to examine info rmal sexual relationships between tourists and locals that are not conn ected to the commercial sex industry. In reality, these informal sexual contacts may be at an even greater risk of STD/HIV transmission. Tourism has long been associated with HIV transmission through sexual contact between visitors and locals in a variety of contacts includi ng both formal, paid relations and through informal relationships. The v acation atmosphere is conducive to casual, often risky sexual relationships for numerous reasons because tourists perceive their environments and social roles differently wh ile on vacation. McKercher and Baur (2003) explain tourism as a liminal state whereby va cationers escape their normal roles and can engage in activities outside normal gender a nd societal constraint s. Moreover, the environment within which tourists find them selves facilitates risky sexual encounters. For example, many tourist destinations are exotic or romantic in nature with many similarly aged people mixing including tourists and locals working in the service industry (McKercher and Baur 2003). Research in th e Dominican Republic ha s shown that those working in hotels as entertainment staff or wa iters are most likely to engage in casual sex with tourists (Forsythe et al 1998). Moreover, younger trav elers and students report changing their behavior while on vacation, possibly due to feelings of anonymity while


36 away from home. Tourists often take on a ne w set of social norms while on vacation that can include binge drinking, drug-use, and adve nture or risk-taking activities including casual sex (Josiam et al 1998; McKercher and Baur 2003; Pruitt and La Font 1995; Smeaton et al 1998). A newer phenomena noted by researchers is that of romance tourism whereby foreign women develop relationships with lo cal men while on vacation. Many of these women do not intend to develop relationships prior to traveling; however many often find themselves with locals. This type of tourism is different from sex tourism because the woman does not view herself as paying for services (although indirectly this may be the motivation of her local partner) but rather being involved in a love relationship (Pruitt and La Font 1995). Local men have discovere d their attractiveness to foreign women and have begun to take advantage of these re lations for economic gains as well as sexual adventure (Herold et al 2001). Foreign women traveling to the Caribbean or Latin America are often attracted to local men who exude an otherness that they consider exotic. For example, some women refer to local men as Latin lovers or having Rasta appeal because they model masculinity, which is often associated with the erotic (Herold et al 2001; Pruitt and La Font 1995). Western women, especially blonde women, are considered exotic and at tractive to locals (Meisch 1995). Moreover, the idea that American women are sexually liberated is at tractive to men who are hopeful something physical might ensue (Meisch 1995). Finally, some women whose body shapes fall outside western ideals may be regarded as more voluptuous and sexy when they travel to other countries and therefore r eceive more attention and feel more attractive to locals (McKercher and Baur 2003). For example, Me isch (1995) explains how this interaction


37 unfolds in Ecuador between indigenous Otav alenos and American women, in particular, the ideal body type [in Ecua dor] is more womanly than th e impossibly slim American ideal, so that young women who consider th emselves fat or otherwise unattractive suddenly discover that they are considered beau ties, and the experience is heady (451). In addition, local men who seek out relati onships with foreign women for sexual and economic gain mention targeting overweight women because they are aware of the likelihood that such women are le ss popular in the U.S. where a thin figure is considered more attractive; these women are therefore more receptive to their advances (Herold et al 2001). Adventure tourism is also on the rise and includes such activities as whitewater rafting, mountain climbing, ropes course s, trekking, ballooning, spelunking, biking, sailing, diving, etc. The basic premise is that tourists seek high levels of risk for a thrilling, exciting, and often dangerous experience (Flucker and Deery 2003). Many younger travelers are attracted to these types of experiences Flucker and Deery (2003) report on how this type of environment w ithin the white water rafting community facilitates sexual liaisons with river guides. For example, they explain that tourists are often dependent on guides for leadership, safe ty, and protection. Gu ides are a skilled, outdoorsy, and usually physically fit which ma y be attractive to clients. Moreover, clients are enmeshed in a setting of risk and adventure in an environment steeped in imagery leading to a desire to engage in sexual activities with guides to continue this sense of adventure and atypical beha vior (Flucker and Deery 2003).


38 Tourism and Prevention In many countries reliant on tourism for a significant amount of their GNP, government authorities and the Ministries of Public Health and T ourism, do not promote aggressive, visual HIV/AIDS prevention campaigns. Economics is the driving force behind virtually all policy th erefore, many governments fear that the HIV/AIDS epidemic will hinder the development of th eir tourism industries and refuse even to discuss it (McEvoy 2000: 231). Stigma is still a persistent force when addressing the issue of HIV and STIs in many countries re aching far into the bur eaucratic machinery running the country. Therefore, many prev ention strategies face opposition when targeting the tourist industry. The misconception by national governments that prevention campaigns are detrimental to tourism is unfounded as demonstrated by the aggressive 100% condom progr ams now running in Thailand. The tourist industry in Thailand has not felt any negative repercussi ons due to their 100% condom education and prevention programs, and in fact, report increases in tourism (McEvoy 2000). In addition, preliminary interviews of tourists visiting the Dominican Republic reveal that most individuals support public HI V prevention campaigns (Forsythe et al 1998). In fact, many tourists feel these campaigns are bene ficial and prove the Dominican Republics commitment to a cleaner, safer environment (Skoczen 2001). Sexually Transmitted Infections: Latin America The rapid spread of Sexually Transmitted Infections (STIs) including HIV/AIDS, has become one of the major public health c oncerns in Latin America and the Caribbean. The World Health Organizat ion estimates that, by the end of 1999, there were approximately 18.5 million people in the region w ho were infected with STIs other than


39 HIV/AIDS. This number reflects a preval ence rate of 71 per 1,000 (second only to SubSaharan Africa) (WHO 2000). In 1996 alone, over 2.2 million people in the area were infected with preventable STIs (VPS 1997). In women, untreated STIs can lead to Pelvic Inflammatory Disease, inferti lity, cervical cancer, ectopic pregnancy, and spontaneous abortions. Babies of infected mothers may face complications such as pneumonia, prematurity, low birth weight, bli ndness, and stillbirth. More importantly, STIs, especially those associated with ulcers and open sores; provide an easy medium for the transmission of HIV/AIDS. As of the end of 2001, the rate of HIV infection in Latin America and in the Caribbean was estimated to be 0.5% and 2.3% respectively. There are approximately 1.5 million people in Latin America and 420,000 in the Caribbean who are currently living with HIV (UNAIDS 2002a). The epidemic spr ead of STIs in general, and HIV/AIDS in particular, is especially alarming amo ng young people (those younger than 24). It has been estimated that 100 million young people around the world become infected with HIV each year (UNICEF et al. n.d.), and that about half of all new infections occur among them (UNAIDS 2002a). HIV and Adolescents On average, 57 per cent of those infected globally are between the ages of 15 and 24 (UNAIDS 2005a). Of the 30 million pe ople that live today with HIV at least 1/3 is between 10 and 24 years of age. (Mendoza 1998). An estimated 2.6 million new infections a year occur am ong young people (7000 taking place daily around the world) (Medoza 1998). There are numerous reas ons that HIV has begun to impact young people at a disproportionately high rate as compared to all other demographics. The


40 period of adolescence compounded with mixed media me ssages, a shifting economy and globalizing world, urbanization, to urism, and a lack of educat ion are all factors, which create an entire demographic group at an increased risk of STI and HIV infection. In the regions of the Americas, one in ever y 200 persons between the ages of 15 and 49 years of age is HIV infected (NewsRX: 2001) However, the majority of HIV/AIDS cases are not reported or discovered until up to 10 years after initial in fection. Therefore, it can be assumed that many infections o ccur during the teenage years (Schifter and Madrigal 2000). Moreover, HIV is becomi ng the leading cause of death among the 2540 year age category (Schifter and Madrigal 2000 ). It is not surprising that young people are less informed about HIV and STIs th an any other demographic group. Many young people receive information concerning HIV from their peers or on the streets. Transmission of often false information leads to risky sexual activit ies and beliefs. An efficacious combatant to this epidemic is th e utilization of educational materials that systematically explain HIV prevention techniques and provide i ndividuals with the resources and tools to protect themselves. Adolescence, a period marked by curiosity, discovery, and exploration, is a stage often times associated with initial sexual e xperiences as well as experimentation with drugs and alcohol. These activities often c ontain added risks of contracting an STI, including HIV, if uneducated individuals are not given the necessary preventative tools to protect themselves. Biologically young people are physically more vulnerable to HIV as their skin tissue is softer and tears and damages more easily during sexual intercourse, allowing for greater HIV transmi ssion. (Save the Children 1999: 19). Sobo (1995:11) notes, teen-aged girls are in a pa rticularly vulnerable position biologically


41 because their vaginal linings ar e not as thick as those of mature women. Furthermore, they are vulnerable from a socio-demographic point of view because they often have sex with older men men who have had more opportunity for acquiring HIV infection. Additionally, the media barrages young people with images that promote sex as a glorified activity often associated with alc ohol consumption and tobacco use. There are mixed messages promoting sexual activity: r obust male vs. virgin females. The implication of these contradictory messages is witnessed in the disp roportionately high rates of females who are uneducated about HIV as well as the negative stigma surrounding an open discourse about se x and sexuality among young women. In the developing world, a populatio n shift among young, mobile populations from rural regions to the urban and tourist meccas is a phenomenon fueled by globalization and private market systems in conjunction with images of western lifestyles and commodities. Today, many young people seek urban job opportunities in hopes of economic gain not realizable in traditional agriculturalist lifestyles. Furthermore, many parents en courage children to seek wo rk in urban centers as commercial farming and other market pressu res are preventing successful family farms from prospering. The risky behavior of young, mobile popul ations has been well-documented (Forsythe et al 1998; Hirsch et al 2002; Nishigaya 2002; Davis et al 1992) and demonstrates the susceptibility young people face as they migrate to urban centers. For example, businesses with a workforce that is young, single, mobile, and poorly educated about HIV/AIDS prevention measures are prob ably at a disproporti onately high risk of becoming infected. (Forsythe et al 1998:278). This, juxtaposed to the statistic that


42 young people compose nearly 30% of the deve loping worlds populati on, paints a rather daunting picture. Moreover, it has been pred icted that five new cases of HIV occur each minute among young people (Mendoza 1998). In many areas of the world undergoing rapid change, young people are caught between globalization and trad itional beliefs. College Students in the United States Research on the sexual behavior of young people in the U.S. has mimicked that of HIV research among the general populati on focusing on risk populations and not on the general population of young people. Some research has been done on college campuses in an effort to understand general patterns of risk and sexual behavior among young people; however, these data are not gene ralizable to all young people. There is even less research on young pe ople who travel and their sexual activities while on vacation. However, there are some studies examining the behavior of college students while on Spring Break. However, these data ar e valuable and presented to give an idea of how some young people while traveling on va cation to Costa Rica or other locations may behave. College Students: Alcohol, Drug Use and Sex By simply following popular media, it is easy to see that college campuses are replete with the use and abuse of both al cohol and drugs. Underage drinking is a common practice of which underclassman tend to partake because of less parental supervision and more freedom and accessibil ity. Research has shown that the most popular drug of choice for students is al cohol, followed by marijuana (Presley et al 1994). Additionally, binge drinking or heavy dr inking, defined as having five or more drinks in a row at a single event, is a common problem on the majority of college


43 campuses (Kapner 2003; NIAAA 2002). Kapner reports that 44% of college students would define themselves as heavy drinkers (2003). Additionally, in a 2002 National Institute of Alcohol Abuse and Alcoholis m (NIAAA) study, researchers found that two out of five college students reported binge drinking with in the previous two weeks (2002). Excessive drinking and the use of drugs, which is associated with the college lifestyle, have implications for risky or casual sexual activities. Several studies document that when drunk or high there is an increased likeli hood of unprotected sex (Bon et al 2001, Gordon and Carey 1996, Testa and Collins 1997). Furthermore, mixing alcohol and marijuana leads to slightly hi gher risk of unprotected sexual activity (Bon et al 2001). Hingson and colleagues examined th e effects of alcohol use on college campuses with multiple health outcomes (2002) Some of their more alarming findings deal with sexual behavior, violence, and risk of HIV transmission. In 2002, they estimated that over 70,000 student s were victims of sexual assa ult or date rape (Hingson et al 2002). Additionally, 400,000 reported ha ving unprotected sex with 100,000 of those reporting not remembering if they consented (Hingson et al 2002). Any unprotected sexual encounter allows for the possibility of in fection. Therefore, statistics such as these certainly raise red flags and s uggest an alarming trend to parents, health workers, educators, and researchers. College Students: Sex, Condoms and HIV An estimated 50% to 80% of unmarri ed college students are sexually active (Murstein and Mercy 1994). Of those sexua lly active, 25% of wo men and 60% of men report having casual sexual relations (Dunn et al 1992). In addition, reports suggest


44 women are more sexually responsible than men are, and more likely to insist on condom use (Lance 2001). Knowing actual rates of HIV seropositives among college students is virtually impossible; however, in 1997 th e CDC reported that an estimated 1 in 500 students could be HIV positive (CDC 1997). Therefore, the risk of HIV transmission is a very real possibility among young people. Young people in the U.S. and college st udents in particular have a very high level of knowledge about HIV and its potenti al modes of transmission. However, they simply do not perceive themselves as being a t risk despite their participation in certain identified risky behaviors. For exampl e, Lance (1995-1996) found that students were very knowledgeable about condom use protecting against HIV, with 85% to 90% of those surveyed correctly answer ed the questions pertaining to safe sex practices (Lance 2001). However, 51% reported that they either always or sometimes had unprotected sex (Lance 2001). Clearly, young people do not perceive themselves as susceptible to HIV infection. In a sim ilar study, McCormack reports that 75% of heterosexual college students do not feel at ri sk for HIV infection (1997). Some of these students may feel like they are not at risk because of being in monogamous relationships. However, reports suggest that 25% of heterosexual st udents are dishonest about their sexual faithfulness (Stebleton and Rothberger 1993). There seems to be a clear fissure between what college stude nts know about HIV transmission and their perception of being at ris k. Students seem to understand what behaviors lead to transmission, yet when they are involved in those activities (even if rarely), they do not feel at risk.


45 College Students: Sex and Vacation Some research has begun to address changing behaviors among college students and young people while on vacation, but anthr opo logy has contributed little to this body of knowledge thus far. Maticka-Tyndale a nd colleagues (1998) have done some basic quantitative research, primarily using que stionnaires, among Spring Breakers to understand their sexual behavior while on v acation. They discovered that men have much greater intentions than women do when it comes to hooking up or engagi ng in casual sexual relations. However, casual sex occurred much less frequently than the men would have hoped. In a particular study she found that between 25% and 28% of students on Spring Break did engage in casual sexual relation s (Maticka-Tyndale et al 1998). Interestingly, they found that men are more influenced by their peer groups and expectations while women ar e less affected by the group mentality (Maticka-Tyndale e t al 1998). Researchers have found that many st udents disregard their normal personal codes; however, very little has been done to examine why such behavior modification exists. Critical Medical Anthropol ogy and Political Economy Anthropologists, sociologists, public health workers, and other scientists have long examined human behavior and culture th rough a theor etical lens developed in the m00s by Karl Marx and Fredrick Engels that is today referred to as political id-18 economy. In the critical publication in 1845, The Condition of the Working Class in England (1962), Engles examines how economics impact the working conditions o f the poor in Germany recognizing th at macro-level processes (c apitalism) and an oppressi ve


46 class system which resulted from capitalism cause increased disease and earlier death among the poor working class (Singer 1998). Vi rchow furthered these ideas by analyzing a typhus outbreak in East Prussia and examin ing what he believed to be the principle social causes of disease identifying unemplo yment, malnutrition and hunger, inadequate housing, and overcrowding as the real culprits in the epidemic (Singer 1998). These pivotal discussions moved health and illness rhetoric beyond the biological and physiological realm and into a discussion of the larger, more complex systems at work that impact health and wellness. Today, political economy is referred to as valu ing the description and analys is of social phenomena in rela tion to political, economic, and historical relations, in both a local an d a global sense (Carlson 1996:268). Singer (1989, 1990, 1995) has incorporated the theory of political economy into a more focu sed approach to understanding health experi ences through the development of Critical Medical Anthropology (CMA). Singer (1995) defines critical medical anthropology as, a theoretical and practical effort to understand and respond to issues and problems of health, illness, and treatment in terms of the interactions between the macro level of political economy, the national level of political and class structure, the institutional level of the he alth care system, the community level of tation intimately tied to complex macrolevel syst ems that reinforce poverty through politics and econom popular and folk beliefs and actions, the micro level of il lness experience, behavior, and meaning, human physiologica l, and environmental factors. (81). CMA recognizes disease as a social product, and not just a phys ical manifes ics. Singer and others developed CMA as a response against tr aditional, clinical medical anthropology. Medical anthropology is accused of being the handmaidens of biomedicine because it perpetuates the power structure of those working in biomedicine


47 lness d g in the uctural there ects of l In uch above those patients seeking treatment (Si nger 1995). In addition, according to CMA proponents, medical anthropology is guilty of cu ltural bias when analyzing health in the developing world using a Western biomedi cal paradigm (Singer 1990). Moreover, Singer (1990, 1995) criticizes medical anth ropology of being too myopic and focusing only on the micro-level structures and individual behaviors that impact health and il and not identifying larger struct ural determinants such as gender inequality, poverty, an social stratification. Singer complains, that medical anthropology assumes the autonomy, self-regulation and boundedness of local groups in local set tings and fails to consider the processes that transcend separa ble cases (Singer 1990: 180) resultin inability to identify root causes of illne ss at the macro-level. Therefore, any transformation that is promoted by medical anthropology is only at the local level resulting in superficial change or health improvement and ignoring larger, str inequalities. Additionally, by focusing solely on the individual and their behaviors is a natural tendency toward victim -b laming. Whiteford and Vituccis (1997) examination of how policy and practice ma rginalize poor, inner-city pregnant women brings to light the effectiveness a CMA approa ch can have in identifying the eff how macro-level structural barriers can result in institutionalized racism and sexism. Moreover, Whiteford and Vitucci (1997) mainta in that by not looking at the macro-leve researchers may in effect be ignoring or furthering an enviro nment of marginalization. the example of poor, inner-city women who ar e unfairly targeted for drug-testing the authors state by focusing on pregnant wo men who use drugs, policy makers and the public have found a convenient scapegoat, and t hus avoiding facing the larger issues s


48 onstrates how victim-b laming manifests itself when medical anthrop sult by ities that result fro m capitalist market systems and po ul ill as the effects of racism, classism and sexi sm on members of U.S. society (Whiteford and Vitucci 1997:1373). Singer (1990) dem ology is rooted in a medical ecol ogy paradigm. Medical ecology promotes the idea that cultures exist within a constric ted, defined environment and must adapt to certain environmental pressures in order to survive and thrive. Illness, then, is the re of an individuals inability to adequately adapt to the environmen t and is therefore in some way at fault for their weakness. Polit ical economy and CMA avoid this mistake maintaining an abiding holis m that encompasses not only that which is immediate and visible but also that which cannot be seen at the microlevel, namely the class relations that structure the local environment (Singe r 1990:180). It is defi cient to study only the local context without understand ing the forces that have shap ed and continue to shape the environment within which people survive, espe cially in a world that is becoming more connected, through globalization, daily. Without revealing social in equal litical maneuverings, there will be a continuation of the poor and powerless being oppressed. In addition, as the former dire ctor of the World Health Organization Dr. Gro Harlem Brundtland (2005) states, poverty breeds disease and disease breeds poverty. Political economy and CMA have both identified the impact of capitalism as a catalyst for developing a highly stratified class system with a wide gap between the rich, powerf upper class and the powerless poor. As gl obalization and technology increase and the rise of multinational companies expand, w ealth will continue to be inequitably distributed. The trend of the poor growing poorer and the rich growing richer w


49 ple in many of these st d acking the c in ddition, CMA examines behavior from the emic or insider perspective. Researc continue. In 1998, UNDP reported that combini ng the wealth of the 225 richest peo the world is equal to combining the wealth of the poorest 2.5 b illion (UNDP 1999). The poor have limited access to job opportunities an d advancement, education, nutrition, and health care. Therefore, it is not surprising that poverty is one of the most significant indicators of adverse health effects and is a risk factor for HIV transmission. CMA, with a political economic context, is able to identify and address ructural barriers that affect health. Through an understanding of the interconnectedness of multiple variab les, CMA moves beyond narrow-minde biomedical understanding of disease being s imply the result of a pathogen att body. Instead, CMA examines social origins of disease, which can include a variety of variables including: political unrest, social upheavals, malnutrition, hegemony, economi insecurity, lack of political power, and overcrowding, to name a few. CMA can change and empower communities, which is what conventional medical anthropology has failed to do thus far. Singer (1995) explains how CMA recognizes the hist orical role culture plays in shaping human behavior. For exampl e, pointing out how m achista attitudes Latin America might prevent men who have se x with men as identifying themselves as homosexuals because historically it is not an accepted sexual orientation in many Latin cultures. In a hers attempt to understand behavior and cognition from the perspective of the individual and the cultural environment within which they identify. This perspective allows for the development and initiation of health education and health care that is culturally relevant and encourages self-determination. For example, HIV/AIDS


50 tural l akers, portant to consider the infancy of CMA when compared to some other theoret cacy. s under examination in this new phase is the ability of critical medical anthropology to move beyond the academy, the scholarly confere For the oretical orientation for applied anthropologists zing health outcomes from the theoretical perspective of critical medical anthropology and political economy un covered? Researchers have found that campaigns developed in Haiti following CMA principles address some of the cul ideas about transmission and the role of witchcraft. Additionally, CMA examines loca contexts in relation to global forces, especi ally economic, affecting these communities. For example, understanding how the interplay of capitalis m, changing economies, and rural-to-urban migration patterns is cha nging sexual behavior among migrant workers and increasing HIV transmission. Furthe rmore, CMA identifies and challenges inequalities by sharing this knowledge with local communities as well as policym and advocates in an effort to educate and em power. These are just some ways CMA is able to understand health and illness at the local level and within the context of macrolevel forces. It is im ical orientations and realize it is an evolving theory that will take time to fully develop. A new phase of CMA began emerging in the mid 1990s with a key component being the movement out of academia into a theory of action and advo Singer (1995:81-82) explains, One of the issue nces, and the academic journal into the applied field of clinics, health education and development projects, federal health research institutes, international health bodies, private vol untary organizations, health movements and community-based agencies. se reasons, CMA is an effective the as it integrates both th eory and praxis. Structural Violence What has analy


51 negativ e ic. social inequalities ranging from raci sm to gender inequality, and the more r e uncontested humans rights abuses, some of them punishments for efforts to escape structural violence (8). Farmer ( e interplay of historical a nd economic conditions pitting th e powerful against the weak. ; social inequalities. The e health outcomes at the local or individual level are tied to global systems, such as economics and politics, at the macro level. One of the most devastating outcomes of these global processes is povert y. Those living in poverty are denied basic human rights: food, clean water, shelter, secu rity, education, and health. In addition, as Paul Farmer (1996, 1999, 2003) explains, human rights can only advance when economic and social equality is realized because al l of these factors are interrelated and working to create th system of deprivation that exis ts today. Poverty, a result of structural violence, is not randomly distributed, but rather continuously disenfranchising part icularly vulnerable populations. Poverty, in turn, breeds poor heal th, which directly fuels the HIV pandem We cannot simply address one of these issues but must look at the interplay of all of these systems, which Critical Medical Anthropology allows us to do. Without profound institutional change and radical social progress, gender-based and poverty driven violence will continue. Farm er (2003) explains how this institutionalization of violence or structural violence is manifested today, as a host of offensives against human dignity: extreme and relative poverty, spectacular forms of violence that a 2003) goes on to explain that violen ce results from inequalities resulting from th Clearly, structural viol ence begins at the macro-level of political and economic systems however, it materializes at the lo cal level in abject poverty. CMA also recognizes that historical cultural ideologies influence health outcomes, particularly in societies that perp etuate gender and


52 majorit triarchal in n being to y of the worlds poor live in the dev eloping world, which te nds to be pa in nature. Males being the heads of hous eholds and often the primary breadwinners characterize patriarchal societies. The majority of Latin American cultures continue to be characterized as machista. Machismo refers to how gender relations are organized terms of prescribed notions of male activity or dominance, on the one hand, as opposed to female passivity and submission, on the other hand (Parker 1996:62). Therefore, there is a clear imbalance favoring the males in th e communities. Furthermore, boys tend to be educated longer than girls are. In the majority of these societies, women have more traditional domestic roles such as keeping the house and children. Mens authority over women is perpetuated through th ese traditional structures and ideologies. A classic example is found in Lesotho where women are considered minors by law their entire lives and given no authority to vote or access credit (Romero-Daza and Himmelgreen 1998) 2 These are just some examples of how politics, economics, class structure, traditional beliefs and norms, and environmental factors all function to institutionalize poverty and gender inequality in many de veloping countries. Gender inequality translates to negative health outcomes among the oppressed. This is the case for wome who have little or no power, especially visi ble in the feminization of HIV/AIDS seen around the world. Today, women account for 3 out of 4 cases of people between 1524 years of age living with HIV in Sub-Saharan Africa and the Caribbean (UNAIDS 2004e). CMA provides an ideal framework to examine the interplay of variables that result in an increase in HIV susceptibility including low socio-economic status, lack of education, lack of access to heal th care, gender-based violence, and sexism in an effort 2 Not surprisingly, HIV rates in Lesotho are some of the highest in Africa with rates among adults reaching 32 % (UNAIDS 2004d).


53 s advocate for progressive social change. In short, disease must be understood as being a much a social as a biological product (Singer 1990:182).


54 Chapter 3: Methods This chapter will provide a description of the different data sources and methodologies used throughout the project. Although this thesis is based only on data collected through focus groups, educational sessions, and pa rticipant observation, I have included information on the methods used in th e overall project, to offer the reader a wider context for the interpretation of my results. The study began in July 2003 and last appr oximately one year. I was in the field from July 2003 until December 2003. I return ed to the field during the summer of 2004 to complete one more focus group and short-term quantitative surveys. Research Team and Tool Development Data were collected over a five-month period, August 2003 to January 2004. In addition to Nancy Romero-Daza, the Principal Investigator, the team was comprised of four other individuals who were stationed in the Monteverde area for the duration of the project. Sophia Klempner, Academic Director of the Monteverde Institute, was the coPrincipal Investigator and overs aw the daily activities of the research team in the field. Noe Vargas, a resident of the region who ha s extensive experience working with health related projects in the community was also re sponsible for data collection. Noe and I had similar research responsibilities includi ng arranging and conducting interviews with community members, facilitating focus groups, and leading group discussions in the public and private schools. In addition, I collected most of the survey data because the


55 majority of participants were English-speaking. Cris tina Calderon was another key addition to the research team. She is a Washington D.C.-based HIV educator who volunteered to help with the development of an educational campaign as well as note taking during focus group discussions The design and conduct of this research were done in collab oration with local community members, from the initial se lection of the topi c to the design and implementation of the project itself. Co mmunity input was obtained through the presentation of the proposed study to the R ed Familiar, a community committee. Red Familiar was developed to address community issues concerning the physical, emotional, and social well-being of the families living in Monteverde. At the time of the study, committee members included both locals and fore igners who live in Monteverde and was comprised of medical personnel, womens ri ghts activists, teacher s, housewives, clergy, and community volunteers. The committee prov ided general feedback assessing the most appropriate culturally sensitive techniques and channels for the collection of information from different segments of the community. Sampling and Informed Consent This project was exploratory in nature and the overall population of the region is small; therefore, the researchers used a simple clustered convenience sample. The research team identified different community sectors of interest such as educators, guides, waiters, etc. After identifying potenti al contacts in each of the sectors, the two field researchers contacted these key individu als through phone calls or by visiting local businesses. Participants were given the Institutional Review Bo ard consent approved by the University of South Florida in Spanis h or English, depending on their language of


56 preference, and then interviewed. Severa l participants mentioned other community members who might be interested in participating or whom th ey felt might share different insight. We followed some of these referrals for additional interviews. Written informed consent was obtained fr om all participants (Appendix A). Those under 18 years of age who participated in the focus groups or educational discussion sessions had to present written proof of parental consent prior to participation. Research Methods Qualitative and quantitative data were collected th rough individual in-depth interviews, focus groups, short surveys, and participant observation. However, this thesis will report data and results derived only from the focus groups, educational campaigns that included discussions in the schools, a nd participant observations Reference to the overall project will be used to contextual ize the data and results when necessary. The research instruments included op en-ended and semi-structured interview guides (Appendix B), focus group discussion gu ides (Appendix C), and short close ended surveys (Appendix D) and was pilot tested prior to the beginning of the study. In-depth Interviews Local community members and long-term visitors are more accessible for longer periods and therefore more in-depth, hour-long in terviews were consid ered appropriate to explore the perceptions of this population. In-depth interviews began immediately after field testing the instruments and lasted until late December, 2003. A total of 57 in-depth, face-to-face interviews were conducted with a variety of individuals who live in the Monteverde area, and who repr esented different segments of the community. Individual interviews ranged from 45 minutes to over tw o hours. Interviews were conducted in


57 either English or Spanish as determined by th e respondents preference Interviews were tape-recorded if the interviewees gave consent. Several of the in-depth interviews were transcribed or partially transcribed. The re maining interviews were written up from the researchers notes. Data reporte d from these interviews will be limited in this paper. The following is a breakdown of each sector and explanation for inclusion in the study: Tourism Sector Researchers attempted to interview as many individuals as possible who had a direct involvement in the tourism industry. Thirty-eight people were interviewed and included those who provided direct services (e.g. canopy tour guide s, taxi drivers, waiters), owners of establishmen ts that cater to tourists (e.g. hotels, bars, internet cafes), those involved in the administration and regulation of t ourist services (e.g. members of the chamber of tourism), and tourists themselv es, especially long-term tourists (i.e., those who remained in the Monteverde area from three months to several years). Education Sector Another purpose of this project was to determine what types of HIV/STI education and prevention activit ies currently exist in the Monteverde area. Additionally, the growing literature on HIV/ STI transmission trends in Latin America suggests that adolescents participating in unprotected, heterosexual sex are at a disproportionately high risk for contracting HIV/STIs (Shifter and Madrigal 2000). In the regions of the Americas, one in every 200 persons between the ages of 15-49 years of age is HIV infected (NewsRx: 2001). Furt hermore, drug and alcohol use in conjunction with early sexual initiation greatly increase the risk of transmission (Bon et al., 2001). Education is a key determinant of risk-taking activities and one that is easily a ddressed. Moreover,


58 young people are particularly vulne rable to outside influences, which are evident in the influence tourists have on local populations The school system provides an accessible channel whereby HIV/STI educational can be disseminated to young people. Researchers sought to interview those individuals who have an intimate knowledge of and experience in the local edu cation system. We were interested in learning about the extent of the problems asso ciated with sexual risk taking among young people and to determine cultura lly appropriate ways to pr oviding STI/HIV education to students. Eleven in-depth interviews were conducted in the three junior high and high schools in the Monteverde area. Seven of these interviews were done with teachers from both private and public schools (including two se x education teachers), and three with the directors of each of the schools. Finally, an instructor who worked with young, adult, foreign students was also included in the sa mple. This group included both Costa Rican and American instructors with extensive experience in the educational field. Government Sector Researchers interviewed political l eaders and those involved in the local government because they have extensive knowledge of the community and the positive and negative changes associated with the grow th in tourism. Interviews were conducted with a local police officer, a municipal govern ment employee, and a member of the local development agency. Religious Sector Monteverde has three main religious organizations/churches: the Quaker community, the Catholic Church, and the Evangelical church. Res earchers attempted to conduct interviews with religious leaders and congregation members from all groups


59 because previous research demonstrates the si gnificant role religious groups can play in shaping community attitudes about sex, risk behaviors and stigma tization (especially concerning HIV and STIs) (amfAR 2004; Shifter and Madrigal 2000). Additionally, education campaigns, especially in Latin Amer ica, can be shaped by religious ideals if the church is highly visible in the community (amfAR 2004; Shifter and Madrigal 2000). Unfortunately, researchers were able to inte rview only three individuals who had strong religious affiliations. All three individuals were members of the evangelical church and included the Pastor, a congregation member and an involved youth member. It is important to note that this is a small co mmunity and many individuals who would have been considered respondents for a different sector, such as tourism, may have been involved members in a certain religious group. We attempted to interview the Catholic priest in the area, but he di d not return our numerous phone ca lls. However, he did allow us to use the church hall for our HIV edu cation campaign and community presentation. In addition, the youth leaders in the Catholic Church refused to be interviewed. Finally, we were able to interview a few members from the Quaker community; however, their answers reflected their profession rather than their religious orientation. Health Sector Finally, researchers felt it was important to interview the primary healthcare providers in the region. There is only one public clinic in Monteverde with a small staff of service providers. The clinic provides basic HIV edu cation through school fairs and organized community functions. Commun ity members can access STI/HIV prevention materials and free condoms if they make an appointment to meet with a healthcare provider. Additionally, the clinic does offe r HIV testing for a small fee or sometimes


60 free. All pregnant women are offered the te st. However, the clinic reports that few people actually ask to be teste d. One of the main reasons may be the system of testing. A blood sample is drawn from a patient and sent to a laboratory at th e regional hospital in Puntarenas, which is located several hours away from Montev erde. Negative test results are reported back to the clinic in Monteverde. Positive test results are given directly to the patient. Therefore, the clinic is able to discern who tests positive if they do not receive a negative result. This system may prevent community members from being tested due to a lack of privacy. Costa Ri ca does have an extensive public health care system and is one of the few countries in La tin American that offers the three cocktail antiretroviral treatments to all HIV positiv e patients (Agua Buena 2005; amfAR 2004). However, patients in Monteverde have to trav el to Puntarenas to receive the medicine because the local clinic does not offer treatment. Surveys Short-term visitors are more difficult to interview for an extended period time than are local residents. Therefore, quic k, 5 to 10 minute clos e-ended questionnaires were designed to access the most amount of in formation in the shortest amount of time. Researchers conducted these inte rviews with short-term vis itors (i.e., those who visited the area for less than one week) at popular local es frequented by touris ts such as internet cafes and bus stations. The survey instrument consisted of 19 questions asking about basic demographic information, travel routes, and STI risk be haviors (e.g., observed drug-use, alcohol-use, and sex with locals, and condom availability in Monteverde ). Over 150 surveys were collected from August 2003 to August 2004.


61 Focus Groups Focus groups and open discussions are effective techniques in soliciting information because they provide an envi ronment that promotes open discussion and debate allowing researchers to listen and probe for specific them es. The data presented in this thesis are taken predominantly from fo cus group discussions. The research team utilized focus groups with the younger particip ants because we felt it would help create an open, comfortable, directed discussion wher eby participants are en couraged to debate and discuss various issues. Focus groups were conducted in November and December 2003 following the preliminary analysis of in-depth interviews. The preliminary results allowed us to target specific themes, which began to emerge in the interviews. Focus group participants were recruited in several ways. I contacted the coordinator of volunteers at one of the schools and arrang ed a focus group with young, female teachers and school volunteers. The womans soccer coach also organized a focus group with players on the team. Additionally, long-term visitors who worked at the Monteverde Institute were recruited to participate in focus group discussions at the end of their stay in the area. Finally, through co mmunity contacts I was able to organize a mens focus group and a long-term female visitor focu s group. These focus groups were conducted either in the respondents place of work (if it was a quiet and relatively isolated location) or in private, residential settings. Overall, the research team carried out six focus groups with over 35 individuals participating. Focus group questions were open-ended with the fac ilitator directing the discussions, which lasted between one and one and a half hours. The focus group tool (Appendix C) is centered on the following major themes: tourism, changing local


62 behavior, STI/HIV risk behavi or, risk groups, local prevention, and possible arenas for more in-depth STI/HIV prevention. Five of the six focus groups were audio taped and transcribed. The Spanish focus groups were not translated to English in an effort to preserve their meaning. The groups were desi gned to reach the per ceptions of different segments of the community and included: One group discussion with young adults betw een the ages of 18 and 30 years who would be classified as longterm foreign female visitors to the Monteverde region. This group discussion was arranged through a private school in the area known for recruiting foreign teachers, particularly from the United States and Canada, to either teach for a year or volunteer do ing various activitie s including grounds keeping, assisting teachers, and coaching or tutoring students. The background of this group was varied; however, the ma jority was younger women who stayed in the area anywhere from six weeks to over a year depending on their role in the school. All teachers and volunteers be gin their time in Monteverde doing community homestays. However, at any point they have the freedom to move into either a different homestay, different local community, and/or live independently. One group discussion with young, foreign women in the area who worked at the local pension or had recently worked there. The pension is a low cost hotel with shared rooms that is frequented by ba ckpackers who are looking for low budget accommodations. Additionally, the pension is the closest hotel to La Taberna, the most popular bar in the area for young people, which is known for facilitating relations between locals and tourists. The women who participated would


63 identify themselves as full-time resident s of the community. All had dated or were involved in relationships with local Costa Rican men at the time of the study. Two group discussions with local Cost a Rican women. One focus group was organized with the help of a local fema le soccer coach and wilderness guide who had developed strong relationships with women in the community. A local Costa Rican woman who worked for a non-profit organization in the community organized the other focus group discussion. The majority of female participants were single and between the ages of 18 and 30. One group was conducted with local Costa Rican men between the ages of 25 and 30 who worked in tourism and have had multiple relations with foreign women. These included a two wilderness guides a hotel receptionist, and internet employees. Finally, a focus group was conducted w ith young adults, both men and women, between the ages of 19 and 25 who were participating in an eight-week biology course in the area. All the participants were living with local families and had frequent contact with Costa Ricans and other tourists. Participant Observation Participant observation is a common technique in anthropology to gather data by experiencing local culture through interaction and observation. Participant observation was ongoing throughout the research project be ginning in June of 2003 when the field school began. I left the ar ea in December 2003; however, I returned on several trips including March 2004, May 2004, and August 2004. Additional observations were


64 carried out on these subsequent visits. A written record of observations was maintained in a field journal. Data were collected in many of the settings where tourists and locals congregate including bars, discos, rest aurants, and internet cafes. In August 2003, when the project offici ally began, there were four major bars/discos in the Monteverde region. Two of these bars catered to a mixed crowd of young locals and tourists. Locals predominantly frequented the other two bars. The majority of late night intera ctions between locals and tour ists took place in the disco located near the Santa Elena town center. This bar was open from lunchtime until 3am and played a variety of dance music including local salsa and meringue music as well as American dance music. Local drug dealers are known to sell marijuan a to tourists in and around the bar. I spent time at the bar, usuall y in the later hours of the evening when the crowds were larger, and observed interac tions between locals and tourists. I am considered a long-term visitor and treated like many of the other tourists. For example, many of the local men were flirty with me a nd often asked to dance or meet up with them for drinks. Therefore, it was easy to understa nd the dynamics between locals and tourists because I personally experienced ma ny interactions with locals. Internet cafes were also conducive to obs ervation. Many of the cafs are owned and operated by young locals and mainly frequented by tourists. I was able to observe interactions and hear numerous conversations while working at a computer. Specific restaurants were also good places to observe in teractions especially between the wait staff and tourists. It was not uncommon for waiters to make plans to meet up with tourists at local nightclubs after the restaurant closed. All of these settings were useful in assessing


65 behaviors (e.g., drinking, use of drugs, and hook ing-up with potential sex partners) that may contribute to the spread of STIs, including HIV/AIDS. During my stay in Monteverde, I coached the girls soccer team, Feminino Monteverde. Local women a nd girls provided a different perspective of tourism and sexual behavior especially sinc e our interactions occurred wh en men were not present.. I also attended the local gym, which was freque nted by locals and long-term tourists. I was able to witness and hear about relationshi ps between locals and tourists. Finally, I occasionally worked at a local restaurant th at was known for selling marijuana (which I did not know at the time I began working ther e). Through this, I was able to witness a small segment of the drug scene. These cont acts and interactions allowed me to become a more trusted and integrated community member. I did not write down specific conversations, only brief descriptions, or su mmaries of conversations and interactions with community members and tourists. In my notes, I do not include r eal names, but give individuals pseudonyms to pr otect their identities. High School Discussion and Education Sessions The researchers facilitated five group di scussions in three schools, both private and public. The purpose of these discussions was to understand th e perspective of young people because they are at an increasingly higher ri sk of contracting STIs and HIV due to a boost in risky sexual behavior and earlier on set of initial sexual ac tivities (Schifter and Madrigal 2000). Furthermore, we hoped to understand the breadth of their STI/HIV knowledge and to determine th e efficacy of existing programs. The format included a forty-five minute discussion pe riod whereby students were separated into smaller groups and given specific themes to disc uss. The topics were similar to those addressed in focus


66 groups and included: local perceptions of tourism and HIV risk behavior, common nighttime activities for young people, dr ug and alcohol use among young people, education and prevention strategies current ly employed in the schools, and efficacy of these strategies. We facilit ated each group encouraging open and honest discussion and directing the participants toward relevant themes when they were sidetracked. Participants were brought back together into a single group following the discussion. They were then asked to write down any que stions they might have regarding HIV/STI transmission and prevention. Our motivation for asking students to write down questions as opposed to raising their hands was to en sure their anonymity. We brought both groups together so that collectively they could hear the questions of all their fellow classmates. A sample of the questions posed is include d in Appendix E. We answered as many questions possible in a thirty minute time period and handed out HIV prevention materials at the end of the session. We visited three high school principals to ask for permission to conduct these discussion sessions. All three ag reed and directed us to high school teachers who helped distribute and encourage the signing of inform ed consents. Teachers were present during two of the five discussion se ssions. We recorded but did not transcribe the discussion sessions. Three sessions were conducted with students from the tw o private schools in the area. Participants were separated by gender for the discussion segment. Two additional groups in the public high school were conducted; however, because of the small sample size the groups were mixed gender discussion. Data collected from the focus groups, participant observations, and education sessions will be the focus of this thesis. The data collected from the interviews and


67 surveys will be used to provide context to my results. I choose to focus on these methods because I believe focus groups conducted with individuals who are pa rticipating in risky sexual behavior will be helpful in assessing the reality of th e situation, beyond the speculation of those in the community who have no first hand experience. Furthermore, they will help identify personal reasons for ta king risk. This information will help guide future research and aid in the development of STI/HIV education and prevention programs targeting specific segments of the population. Data Analysis All but one focus group session was record ed and then transcribed. Education sessions were not recorded because of the partic ipation of students under 18 years of age. However, observations were noted and questi ons of the participan ts in the education session recorded. Interviewers took extensive notes during th e in-depth inte rviews, even if the interviews were recorded. We expande d on the notes by typi ng them up as soon as possible after the interview. This allowed us to fill in any missing data that we were not able to write in at the time of the interview. Quantitative data were inputted in excel files to be analyzed. All the data were saved in multiple locations and the original interview write-ups were stored in locked filing cabin ets at the Monteverde Institute separate from signed consent forms. We conducted a preliminary analysis of completed in-depth interviews in late September 2003. The data were analyzed usi ng basic content analysis. Major themes were extrapolated and then further analyzed through word searches to recognize patterns in these themes. Each of the interviewe rs performed independent analysis on the interviews they individually conducted. We then met and di scussed the themes we had in


68 common or any notable discrepancies. At th is point, we made minor changes to the interview tool. We added probes for condom av ailability, condom use, and the definition and prevalence of machismo. We did not us e computer analysis because some of the data were in Spanish and some in English, and ne ither of us is proficient in this type of software. Furthermore, we did not have consistent access to qualitative data analysis programs while in the field. Final analysis was conducted in May of 2005 using the same methodology utilized for the preliminary anal ysis. Preliminary results have been presented to the community. The researcher s conducted community presentations with families that host students and volunteers in their homes. Additionally, three short dramas in the communities of San Luis, Monteverde, and Santa Elena in November 2003 were performed to demonstrate strategies for talking with students and tourists about safe sex. Study Limitations This study was exploratory in nature with the main objec tive of identifying cultural domains (Schensul et al 1999:262). Researchers want ed to reach a point of informational saturation (Schensul et al 1999:262) that is demonstrated by sufficient redundancy (Trotter and Schensul 1998). Overall, sample size was small because the study was designed to provide ba ckground information for a larger study in the future. Because sampling was not done in a random ized way, the results might not be representative of groups other than the ones included in the study and might not be generalizable to other settings. In an effort to reduce interviewer bias, both researchers conducted several initial in-depth interviews together, one researcher leading the intervie w and the other taking


69 notes. Following these interviews, techniques were discussed and analyzed to establish a homogenous interviewing style. However, some bias may be inherent because of the sensitive nature of the subject coupled with the fact that I am not a local resident, am female, and Spanish is my second language. For example, my ge nder and nationality may have resulted in some interviewees al tering their responses or silencing some perceptions that they may have been more in clined to share with Noe, or another local interviewer. However, we attempted to me diate this potential bias by building rapport with the participants. Moreover, the re searchers did not ask any direct, personal questions concerning the interviewees sexual preferences or activities. Questions were based solely on individual perceptions. Participants were originally compensa ted for their involvement; however, during the initial interviews several re spondents stated that they pr eferred not to be compensated and wanted to participate because they were aware their information would be useful to the community and not for economic reasons. Researchers are not new to Monteverde and continued research in the future in this region seems certain. Therefore, community members felt that using monetary compensati on would be detrimental to the community in the end because it would become an expect ation. The negative consequence of such a trend might lead to the disinterest of community members from becoming involved in worthwhile studies if there is not a monetary reward. Ther efore, the researchers did not provide monetary compensation to participants (a change in protoc ol that was approved by the USF Institutional Review Board). This change did not seem to effect overall participation.


70 Finally, it was difficult to quantify th e total number of re sponses per theme because of the focus group methodology employed. The format was an open discussion with individuals within the groups respondi ng and others disagreeing or agreeing with their responses. However, results presen ted were confirmed th rough triangulation with other individual interv iews, surveys, or participant obs ervation. Due to the sensitive nature of the subject, participant observations were particularly valuable in witnessing local and tourist interactions, especially in th e nightlife scene. Observations in the field, especially concerning such act ivities as excessive alcohol use and public displays of affection, helped to confirm what some re spondents mentioned, as well as actions or activities that some may have been to o embarrassed or ashamed of admitting.


71 Chapter 4: Results and Discussion Theres A LOT, A LOT, A LOT, A LOT of sex out there, on th is mountain, like it happens unbelievably. I mean it is more that I have ever seen than in any other small community. This chapter presents the main resu lts and discussion obtained through the nested study. Each resear ch objective is st ated followed by the major themes that emerged. In addition, there is a brief disc ussion of the data and pertinent background information It is important to note that because the data presented here derive from focus group discussions, it is impossible to report on specific numbers of responses. Rather, the results are presented in th e form of general recurring themes. RESEARCH OBJECTIVE 1: Understand the general characteristics and changing nature of tourism in Monteverde. When asked to comment on tourism in Monteverde, the majority or respondents mentioned the growth in tourism as well as the changing demographics of those visiting the region. Moreover, respondents felt the a ddition of long-term visitors plays an important role in boosting the economy, and influencing behavior among the local youth. Long-term tourists are defined at those indi viduals who visit the region for an extended period of time ranging anywhere from six weeks to several years and often include language students, university students, t eachers, teaching interns, and community volunteers with various organizations such as Habitat for Humanity and the Butterfly Garden.


Changing Tourism in Monteverde 72 Figure 5. Adventure Tourism in Monteverde Monteverde has always been a popular tourist region in Costa Rica. Of particular fame are the various Reserves and Naturalist Programs that are well known internationally among ecotourists, biologists, birdwatchers, and naturalists. Tourism is currently Costa Ricas greatest economic resource and all respondents noted the growth of tourism in the Monteverde region. Additionally, an interesting trend that was identified by the majority of the local residents interviewed is a shift in the type of tourism that now visits Monteverde. Respondents explained that while in the past, the tourism industry targeted naturalist and birdwatchers that usually visited the area with their families, today there is a new focus on the younger, adventurous, budget traveler backpacking across Central America or throughout Costa Rica. Focus group participants referred to this type of traveler as adventure tourists. In an effort to increase this type of tourism in the region new attractions have been developed in Monteverde and include canopy tours (i.e., zip lines that allow tourists to fly through the rain forest canopy), horseback rides, 4-wheeler tours, butterfly gardens, and insectariums. One respondent explained this shift in tourism as follows: before 100% of the tourists that came to Monteverde visited the Monteverde Reserve, but now close to 200,000 tourists come each year and only 60,000 visit the Reserve, the rest is adventure tourism.


73 Figure 6. Pension Santa Elena Respondents noted a change in the types of accommodations available to tourists. Several people explained that in the past there were fewer hotels and that the majority was geared toward families and eco-tourists that traveled the difficult road up to Monteverde and were willing to pay a higher price for better accommodations. However, today, a backpacker can arrive on inexpensive public transportation. A bus ticket from the capital to Monteverde is less than $5.00 and tourists are able to spend the night at any number of pensiones which cost only $7 to $15 a night. A pensin refers to a small hostel or hotel that has scant accommodations and is geared towards frugal travelers. One of the most popular backpacker hotels is the Pensin Santa Elena. This hostel charges only $5 to $7.50 a night. Rooms are sparsely decorated and guests have bunkmates and share bathroom facilities. However, many backpackers prefer this type of lodging for the cheap price and for the opportunity to socialize and meet other travelers along the way. Many respondents identified these young, adventure tourists, or backpackers, between the ages of 16 and 30, as one of the demographic groups particularly vulnerable to HIV transmission because of their age and vacation mentality. Many young people mention vacation-mode as the tendency to increase alcohol and drug consumption as well as behave less responsibly while on vacation because they feel less inhibited and


74 free from normal, everyday constr aints. It seems that visitors are more likely to cheat on their significant others while on vacation because they have the sense that they are less likely to be caught. On e respondent mentioned, What happens in Costa Rica stays in Costa Rica. Additionally, some respondents felt that thes e younger tourists with a vacation-mode mentality could be responsible for bri nging HIV to Monteverde. One respondent explained, Drugs, for example, it seems that [tour ists] introduce many things here that worry me a lotyes, drugs. Drugs are related to tourism. Also, there are things, for example diseases, that are able to be introduced with tourism. There have been some people, not a lot, that have arrived here with STDs or AIDS. There are no specific statistics that mention the number of HIV positive people in Monteverde. Opinions within the community range from virtually no cases to an overabundance. Unfortunately, records on HIV and STDs are not kept at the community level and provincial records are incomplete due to a lack of testing and inadequate reporting (Personal Communication Nurse at Health Clinic) Long-term tourists/students Another factor that plays a vital role in shaping the social and economic scene in Monteverde is the proliferati on of longer-term visitors (i.e., those who remain in the area for 6 weeks or longer). Montever de is host to numerous instit utions that bring foreigners to the area for an extended period. For exampl e, there is a Spanish language school in the area, which maintains a high turnover of students. These students not only come to Monteverde to study Spanish, but also to ha ve a cultural expe rience and therefore spend their time living with local Costa Rican families. Students can be in the area anywhere from several weeks to several mont hs. These students often migrate between


75 Figure 7. CPI Language School in Monteverde several different sites within the country. The Monteverde Institute runs similar college course/education programs whereby students stay with families in the community anywhere from six weeks to six months. These students often develop strong ties with their host families and their local peers within the community. The Creative Learning Center (CLC), the Friends School of Monteverde, and the Butterfly Garden all host volunteers and teachers. These foreigners often spend a longer amount of time in the community with some volunteers living in Monteverde for several years. The two private schools, the CLC and the Friends school, recruit teachers from the United States to come to the region on year long contracts. The administrators at these institutions noted that the majority of volunteers who come to the area are young women from the United States (between the ages of 17 and 25). None of the respondents was able to give a reason for the marked difference between the number of male and female volunteers. Several respondents noted that when younger students come to Monteverde, particularly those under the drinking age in the U.S. and without the supervision of their parents, they behave in ways that might increase their risk of HIV/STI transmission including drinking heavily, using drugs, and hooking up or becoming sexually involved with local Costa Ricans. One respondent explained:


76 the majority [of tourists/student s] want to do everything that is possible. Its interesting with the students, they come very young, and they take advantage of their time here. Supposedly in the U.S. they are not allowed to go into bars before they are 21, therefore, they arrive here and it is incredible to see how they start drinking, smokingthey seem like Ticos [lay term for Costa Rican] who are 13 or 14, and in the stage of craziness and experimentation. The vast majority of students from the language programs and the Monteverde Institute participate in family homestays wher eby they live with a local family for all or part of the duration of their visit. Local respondents were therefore able to provide comments based on their observations of the behavior of these long-term visitors. The purpose of the homestays is to provide student s with a hands on cultural experience that allows them to partake in the daily lives and activities of the local population. Respondents reported that the homestay expe rience often facilitate sexual relationships between locals and tourists because it bri ngs young people into constant contact with each other. Many homestay participants iden tified negative, disrespectful behavior of visiting students; The students, during the day, do their pr ojects, and then they arrive at the houses in the afternoon and at least one day a week, during the night, they go to La Taberna, it is the preferred placethe majority of them want to do everything possible. It is interesting with the st udents, the ones that come are very young, and they take advantage of their time here. Supposedly, in the United States they do not have permission to go to the bars until they are 21. Therefore, they come here, and they are 18, but act like 13 or 14 year olds and they want to experiment in the craziness of the nightlife. And it is incredible how they drink, and smoke and do other crazy thingsexperimenting. However, they felt that the positive aspects to hosting students outweighed the negative. For example, many families felt hosting stude nts would improve their English speaking skills and those of their ch ildren. However, one of the main incentives for hosting


77 students is the added income local families receive. The Monteverde Institute (MVI) pays families $12 per night, for three meals and lodging (laundry services by family are optional). Similar rates are paid by the Th e Centro Panamericano de Idiomas (language school) (Sophia Klempner, personal communication). Therefore, the majority of families are welcoming to students in spite of the ac t that many worry about the influence foreign students might have on local youth as one respondent explained, for me, the thing that worries me the most are the homestaysit is a more serious problem because the students stay directly with families and there is a direct impact, and they have more liberal sex education. If a young person stays with a family, well, they are going to impac t the local adolescents that live here. Many of these long-term visitors inte nd to remain in Monteverde either permanently or for an undetermined amount of time. Several respondents mentioned that because of their lengthy stay in the area these visitors directly influence the behavior of the local youth especially through their esta blished friendships. For example, several locals mentioned a group of hippies who have taken up residence in San Luis, which is a community located a few kilometers outside of Monteverde. San Luis does not rely on tourism, but is predominantly agricultural However, the MVI has recently begun using San Luis as a homestay community for some of their students. Until this time, San Luis has been isolated from outside influences. Many of the residents seem to prefer a more traditional lifestyle. Therefore, there was some controversy generated by the presence of a small group of Americans who were hoping to move into their area and host a music festival. There was a town m eeting to attempt to block this group from buying land in the region because the locals felt they would be a negative influence. In one focus group a local participant said,


78 there is a group that has come to San Luis and they look very strange, it is group of people that they say walk around naked in their bus and in the farm, these are the things that are coming and disturbing the peace of the pueblo. RESEARCH OBJECTIVE 2: Assess the pers pective of different segments of the local population, about the potential role of tourism in the spread of sexually transmitted infections (STIs). Changing Family Dynamics According to respondents, changing economic s in the Monteverde region can be associated with behavioral changes that are directly influenced by the influx of tourism and money. Many respondents noted the fact that families are now investing more resources, especially labor, as demand for serv ices geared toward tourism increases. For example, many residents, both men and wome n, are now working as guides, bartenders, waiters, and hostesses. Moreover, several re spondents mentioned th e trend within the community to convert part or all of their pe rsonal residence into p ensiones to provide accommodations for the thrifty travel. In addi tion, many families have converted part of their porches or the back of their homes into small eating establishments where the women in the house provide meals dir ectly from their personal kitchens. In the past, Costa Rican families demonstr ated a traditional family structure in which the male in the home was the primary breadwinner and the woman maintained a more domestic role as housekeeper and prim ary caregiver to the children. However, today in Monteverde both men and women are entering the job market. With such trends, many of the younger children, especi ally teenagers, are no longer under adult


79 supervision. According to respondents, this la ck of adult supervision and involvement in the lives of their children can lead to risky behavior. As one respondent explained: There is a large enough population in which the wife and the husband work outside the house and the kids go to school alone and they leave them alone after schooland the kids do what they want because the parents dont have time for the kids and they lose their authority, th eir respect...the parents dont have time or energy to dedicate to the kids Likewise, as more employment opportunities are available during the high tourist season (mid December to early April) more t eenagers are leaving school early to fill these jobs, which pay fairly well. Therefore, young locals are in more direct contact with tourists during the high seasons. Many of these tourists are known for inviting tour guides, waiters, receptionists, and others workin g in the tourist industry to socialize at night in the local bars and clubs. Responde nts noted that as young people work in the tourist industry there is potential for them to be invited out for drinks or drugs, which are activities that tourists on vacat ion are more apt to be involved. Moreover, during the high season locals are earning more money that a llows them the opportuni ty to socialize and purchase drugs and alcohol with their own resources. Many ol der respondents cited this trend of independence and exposure to touris ts on vacation as causing an emersion into the party scene increasing immoral and disr espectful behavior. According to older respondents, this exposure to increased resources and interaction with the party-scene has led to a disruption of traditional values and morals resulting in what the older population would consider unacceptable behavior. Many parents and older people say that younger people are no longer respectful, and they do not wait. They have a boyfriend and the next week they are sleeping together. This is what I hear from parents and grandparents, that today it is only about sex and not about love.


80 Changing Behavior: Alcohol and Drugs in Monteverde Overall, there appears to be a cons ensus among different sectors of the community about the clear effect of tourism on life-style changes that may increase the risk for STIs among local people. Behavior change is particularly apparent among adolescents and young adults who are believed to be much more vulnerable to outside influences. Respondents implicated tourists in a wide variety of lo cal behavioral changes from the increase and acceptance of homosexuali ty in the area to changing ideas about tattoos, hairstyles, body pierci ng, clothes, and music preferences. All of the groups represented in our sample mentioned increasing rates of alcohol and illegal drugs. In particular, respondents connected the increasi ng party scene associated with tourism and vacation as directly affec ting local attitudes about al cohol and drug consumption. Participants believed that re gardless of the type of drug and the mode of ingestion, increased consumption of illegal substances is closely tied to higher rates of risky sexual behavior. Many of the respondent s mentioned that locals, especially young people, are frequently involved in unprotec ted casual sex while under the influence of alcohol or drugs with tourists whom they barely know. One interviewee explained, In the nightlife places ther e are all types of tourists. In these tourist places, there are a lot of very pretty, very sexy gi rls. For the men it is a game during the night to try to conquer the best girl. In reality, all the Costa Rican men have opportunities. What I have seen in La Taberna is that there are a lot of men waiting for a girl to be alone so they c an invite her to dance and invite her for 2, 3, or 4 beers. After that they are ve ry drunk and then men take advantage of this. Finally, respondents id entified the growing economic independence of young locals as being a factor in increased alcohol and drug use because they now have the resources to purchase drugs and alcohol.


81 While many individuals be lieve that the drug problem involves only marijuana, participant observation and interviews with those directly involved with drug use and dealing revealed different trends Drugs that were mentioned included: marijuana, crack cocaine, cocaine, acid, mushrooms, and a loca l drug called reina de la noche (queen of the night). There are no repor ts of injection drug use in the area although this may soon follow especially since injection drug use is on the rise in San Jose. Riehman (1996) for The World Bank (1996) reports that in Costa Rica there is approximately 33 Injection Drug Users (IDUs) s per 100,000 re sidents and HIV transmission among IDUs has been identified. These data are or iginally from 1992, so it can be estimated that these numbers have increased. In addition, contrary to the belief ex pressed by many that tour ists bring in drugs with them, when other drugs are available it is often local Costa Rican dealers who bring them and supply a group of local regulars a nd tourists. The major ity of the tourists interviewed reported that drugs were purch ased in Monteverde as opposed to being carried into the area from other parts of the country, the United States or their country of origin. Participant observation revealed that there is a steady drug flow to the area and local dealers are distributing these drugs in a select few locations frequented by tourists. In addition, one dealer was known to approach tourists and directly offer and supply them drugs, as opposed to tourists having to s eek out sources. Focus groups with students revealed that the majority of participants were aware of the dr ug scene and many could even identify one of the more public dealers in the area. One re spondent answering the question about drug buying explained: Yeah, they only got like one guy whos dealing and like everyone knows himI know other tourists who buy from this guy.


82 Changing Behavior: Sex Local respondents noted an increase in casual sexual relations and many implicate tourism as the catalyst for this change. Reportedly, the majority of casual sex is between local men and foreign women. Foreign wome n are perceived as being more sexually liberated than local women and therefore more desirable. Moreover, local men who tend to seek out foreign women explain that local women are too difficult and controlling whereas foreigners are more trusting, independent and carefr ee. Therefore, local men feel less pressure when they engage in sexual relations or romantic relationships with foreigners. Some local Costa Rican men perceive foreign wo men as more interesting and exciting than local women. Moreover, the pr eference local men show for foreigners may be changing the behavior of local women. For example, one respondent said that foreign women are more sexually aggressive often kissing and being physical in public with Costa Rican men. She also said they ha ve more freedom and fewer inhibitions. Therefore, local girls are st arting to mimic sexually libera l tourists. One respondent explained, I dont know if it is because of touris m or the social development that is happening, but the issue is the sexual confusion there is with both sexes. Perhaps it is with couples that have h ad diverse sexual experiences that is making the people change their mora ls concerning sexual behavior. Therefore, already there are change s in homosexual and heterosexual behaviors. The early onset of sexual activity in the region has been noted by those working in both the public and private education systems who have witnessed growing numbers of teenage pregnancies in Monteverde. Several informants identified the problem of girls dropping out of school at increasing rates due to


83 pregnancy. In addition, a counselor in one school mentioned increasing number of girls asking to be put on birth control. One respondent explained, there are many girls who have to leave high school because they are pregnant. There are mountains of cases, but not just students, there are other young girls that arent in scho ol and they also [end up in the same situation]. Another alarming trend noted by many respondents is the pervas ive mentality that the most important reason for using condoms is to prevent pregnancy and not sexually transmitted infections. Many info rmants, within the school system and those working in tourism, suggested that using other forms of contraception such as the pill or injections often leads to a decrease in the use of condoms. Moreover, as reported by many respondents, in some more conservative segments of the population, especially th e more devout Catholic and Evangelical families, there is hesitation in openly discussing sex and sexuality. Respondents felt that sex is still a tabo o subject for older people who continue to believe young people should be virgins until they are married. Several respondents explained that parents would be against young people having condoms because it is suggestive of what they perceive to be immoral behavior. One young woman explained that if her mom found a condom in her purse or bag she would kill me! Another explained, before [our culture] was accustomed to young people being virgins when they got married. Bu t now it is not like that although parents continue to have the idea that their children are not having sexual relationships when they are single. However, in reality young people are having sex from when they are 13 years old and it is costing us to not open our eyes to it.


84 In one of the focus groups, there was a brie f discussion of local men having sex with minors in the community. This issue is cu rrently under investiga tion in the community and local authorities are aware of the accusations. The data also indicate that same-sex relations and group sex do occur in the area and are often associated with a party at mosphere although there are incidences where this is not the case. The majority of respondents identified ho mosexual and bisexual relationships as being predominantly am ong women. Group sex can involve one woman having sex with several men one at a time, or with several women with a group of local males. However, there have been scenar ios reported where couples engage in group sex or swapping. In one focus group, the participants answer ed the question: Interviewer: Do you think that there is sex with multiple people going on in Monteverde? OH YEAH! Sure, absolutely I mean all of a sudden there are seven people in a room, or three people, or four people, wanna buy a vowel? There is almost always one gringa and 4 tico boys Yes, Yes, there is definitel y a lot of people sharinglike with friends One group of respondents mentioned the impact stigma plays in masking homosexual and/or bisexual relationships. Costa Rica still maintains a traditional culture that does not openly embrace homosexuality or bisexuality. Locals suggested that tourism plays a role in in creasing the numbers of homosexual and bisexual couples. Many respondents felt that the majority of these alternative lifestyles were among foreigners, but did note changing behavior s among locals. For example, one woman identified the problem of local married me n being homosexual and having male partners, but hiding this behavior. This mentality can be dangerous in terms of addressing HIV


85 and STI risk behaviors, especially among thos e who do not consider their behavior risky or are driven to hiding their activ ities. One respondent explained, There is also a lot of bisexuality happening, but here they mask it by bringing in one woman and four guys It is just something that I have seen over and over again, where they say that ther e is a lot of bisexuality and curiosity and they ma sk it because there is stigma, because they dont want to be labe led that way. It is fine if you participate, but you dont want to be labeled that way. It is not uncommon for fore ign women living in the area for an extended period to develop relationships that are more serious with locals. In some situations, foreign women have married local men. However, in the majority of relationships local men will focus their attention on one woman until the end of her stay. Then when she leaves the country, he will move onto a different wo man. Some of these women take the relationship seriously, viewing it as a comm itted, trusting, monogamous relationship with deep romantic feelings, and may be less likel y to use a condom. Participant observation revealed that many of the foreign women w ho had decided to permanently move to the area did so because they were in relationships with a local man. Men who were in these relationships reported a decrea sed use of condoms because they themselves view it as a trust relationship, for however short a peri od they might find themselves with that particular woman. For example, one male respondent explained, It [the use of condoms] depends on th e girl. If all of a sudden one night you meet some chica in La Taberna [one of the main bars in town] and the same night you are going to have sex with her, you worry about having a condom available, but if she is a girl that you have a more established relatio nship with, say like for 15 days or a month, then you are both abl e to know each other better and have more faith in them. Interviews and participant observation reve aled the growing trend among the young local males of being fathers to children from perv ious, short-term relationships with foreign


86 women. Many of these men have never phys ically met their ch ildren who often live overseas, but only communicate with them or their mothers vi a the internet and phone. Condom Use and Availability in Monteverde Respondents identified the preference of many local men to have sex without a condom as one of the major factors leading to unsafe sexual activities. Many of the focus group participants reported that using a c ondom decreases pleasure. In addition, as reported, asking to use a condom is viewed as suggesting that someone in the relationship is sick or is cheating. In one focus group, women reported that local men sometimes claim that they are sterile or that they have already tested negative for HIV as a means to influence a woman against using a c ondom. One respondent explained: theyll [local men] use anythi ng. Theyll use anything to get away without [using condoms]. Th en they will even throw it on you, how come, Im not sick, ar e you sick, do you have something to hidewhy do we need too? If Im not sick and youre not sick then whats the problem? Lack of condom availability was also cite d as a reason for risky sexual behavior. Participant observations and interviews uncovered the fact that condoms are not available in bars, discos, or other places where casual relations are in itiated. They are available from the local clinic for people who have a doctors prescription. However, interviewees felt that it was predominantly local women going to the clinic for womens health exams who would ask for condoms or other forms of contraception. Local men said that they rarely, if ever, used the clin ic to obtain condoms because th ey do not like the quality of the condoms supplied. Condoms are availabl e in the local supermarket and some convenience stores, but accessibility after hours is very limited. All of the stores in the area are closed by 8 oclock at night. There are no condoms available in the most popular


87 tourist bar, or in any of the hotels. The one bar that does have condoms available is the disco frequented by older locals and very few tourists. The condoms at this bar are behind the counter and a custom er would not be able to purchase them in a subtle manner. This bar closes at 11 oclock, which is much early than the tourist bar. In one focus group, the women said that men were never prepared before they went out at night. However, if the woman supplied a condom th en the man will wear it. One respondent explained what often happens, I dont know what it is. I dont know if they assume that they dont need [condoms], or you know what I mean, 9 times out of 10 the girl will be so drunk sh e will just give in to them. Additionally, local men expresse d concern over the quality and effectiveness of available condoms. Some men mentioned that not ha ving money to buy condoms was a factor in their limited use. In addition, responses from students and other local men revealed that younger people might be more embarrassed to buy condoms than older ones. Since Monteverde is such a small community, it is likely a young person will know someone standing in line or the cashier and they fear their actions may be reported back to their parents. One respondent explained, You have to understand certain aspects of our culture or our religion. The fathers and mothers dont accept that thei r children carry around condoms. They dont accept that young people have [sexual] relationships The culture is changing a lot and it is difficult to get the adults to open their eyes. For example, before we were accustomed to people getting married as virgins and now it is not like t hat, but the parents still hold onto the idea that their kids dont have sex when they are single. Some local women were also hesitant to use condoms, especially if they were involved in what they perceived as trus ting, monogamous relationships. One local woman explained,


88 The only protection would be to us e a condom, but excuse me, to use a condom is the saddest thing. It is like eating a banana with the skin on, nobody likes it, very few people like it. Prostitution and Gringeros There were no reports of sex tourism in the area, although this is a flourishing industry in other regions of th e country. One informant who previously worked as a taxi driver in the capital city explained pros titution as a flourishing industry with some women making more in one night than what mo st people make in an entire week. He mentioned that when he was in San Jose he would drive clients to known locations where prostitutes work, and was aware of several locati ons specific to transvestite prostitutes. He felt it was only a matter of time before prostitution would make its way to Monteverde. A few respondents mentioned a select few cases of local prostitution; however, they noted that it wa s contained only within the co mmunity and did not involve tourists. However, an interesting phenomenon described by many respondents was the existence of gringeros. These are young Costa Rican men, between about 16 and 30 years of age, who actively s eek sexual relations with fo reign, especially American women (commonly called gringas). Several respondents felt that local men dating and having sexual relationships up with foreign women for extended periods was a form of prostitution because these men often lived o ff the womens money or were motivated by the possibility of traveling with the woman to the United States or getting a green card. Other respondents felt local men pursued American women because of the possibility of going with them back to the United States. In one focus group one respondent explained, A friend of mine, we were in Manuel Antonio [a popular beach on the west coast of Costa Rica], she met a guy and for the rest of the


89 trip he was with her, staying with us. He did not have 1 colon [the local currency] the entire trip. She paid for everything. And she rationalized it, Ive never had an or gasm like that before. He was traveling all around the country with her, he just went along, the WHOLE time! Another respondent followed with the following remark: Oh God, that happens all the time! ALL the time! You see it happen here [M onteverde] ALL the time! Because this [the hotel they work at ] is like the place for guys to do this. Conversely, many respondents felt the motivation was strictly sexual adventure as locals, both men and women, hold the belief that Am erican women are less sexually inhibited than Costa Rican women, and therefore are mo re interesting sexual partners. Similarly, they noted the ease of being involved with women for short periods of time, which limited commitment and allowed for a higher turnover of sexual partners. Many respondents recognized these behaviors as forms of prostitution. For example, one woman explained, Literally, I have [Costa Rican] friend s who make a living, MAKE A LIVING, off hooking up with tourists, just one after another and they get to go to the beach, get dinners paid Machismo Machismo is a term that traditionally refers to male behaviors and attitudes, which suggest the man is the head of the house and has authority over all ot hers. Machismo is often defined as a somewhat pompous att itude whereby men consider themselves superior, especially to women, and therefore given the ability to make all major decisions for both themselves and their family with li ttle to no input from others. Additionally, being machista or macho means that the man has more sexual freedom and little need


90 to justify actions or behaviors to his famil y. The idea of the male being in control is tradition, but seems pervasive in the area. Female participants in one focus group mentioned this attitude as impeding condo m negotiation between themselves and their partners. One respondent explained: There is a lot to be seen with th e pressure to be a man or be a woman. For example, when you ar e in bed and at the point (of having sex), for the woman to ask that a condom be used is something outside of what should happen, it is not so supposed to be like thatI think that there is pressure, for the men to be a certain way and for the women to be a certain way [where women are submissive and men are in control]and in a situation that intimate there exists a pressure t hat we continue in traditional patterns. Many respondents feel machismo still exists in Monteverde, which can lead to infidelity. Women, in particular, felt that because of tr aditional machista att itudes men continuously sought new sexual partners to prove their manho od. Moreover, a machista attitude is also associated with strength. T hose who are strong are healthy an d not susceptible to injury or illness. This attitude is relevant to ideas about condom use and HIV transmission. Some respondents did not see themselves at risk because they consider themselves young and indestructible. One of th e local nurses explained the di fficulty in educating men in general, The majority of those that DONT come [to the clinic] are men. Also, when we go to the houses to give information [about health issu es in general], or to do anything related to health, you never find the men [willing to listen]. Why dont the men come? They think they are health y and that nothing is going to happen to them. They say, I AM HEALTHY And if I have something, the flu, I am just going to wait it out in the house. Interestingly, several male respondents be lieved that local women were becoming machista. They stated that local women ar e learning the liberal, independent attitudes

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91 common among many foreign visitors and beginning to demand their own autonomy and independence. Local men often stated this as a negative impact on the community. They mentioned that women were getting jobs and working outside the home. This new financial freedom allows them the ability to socialize at nigh t at local bars and restaurants. Many older res pondents looked negatively on this trend and felt that local women who went to bars were a disgrace a nd a disappointment and at greater risk of contracting HIV or having an unwanted pr egnancy. One interviewee explained, Now there are a lot of young [local] wo men working in tourism. They are moving out of their houses with a lot of money and looking for cheap places to live. They live in groups. This [situation] facilitates [sexual] relations with men. When they are no living together with thei r families they are at greater risk. For this reason, pregnancies are increasing too much here. Conversely, women who are independent were excited about the way gender roles have been changing and felt that their economic, so cial, educational, and political freedom was a necessary, positive step forward although they identified the stigma placed on them because of their new gender roles. Inte restingly, American women noted the double standard emerging within the community. They noted that American women are desirable to local men because of their i ndependence and liberal attitudes whereas Costa Rican women attempting to reach a sim ilar level of independence are chastised. I mean you can walk into [the bar] on an average night and you can point out the Ticas that are there by themsel ves and you know basically, if you ask around youll hear all kinds of shit about the girls that are there on their own Because of a negative stigma? Oh YEAH! Oh yeah, you know she does DRUGS, she SLEEP AROUND, shes a SLUT, shes a WHORE, you know? And then if you talk to the girl shes ju st an average girl, you know?

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92 Mobility Respondents did not directly identify population mobility as increasing HIV or STI risk. However, research has alrea dy shown how population movement affects HIV (Forsythe et al 1998; Memish and Osoba 2003) and locals did mention various types of migration, of both locals and tourists, that s hould be considered. Participant observation and interviews did identify the common phenomenon of locals who travel to other regions for work, especially in the slow tour ist season. For example, one local informant traveled to the beaches during the rainy season to work as a waiter, and then returned to Monteverde during the busy season worki ng in whatever position he could find. Moreover, several locals menti oned traveling to beaches or other tourist destinations for fun and relaxation when the season was slow. Interviews and participant obs ervation also revealed the vast number of different vacation spots visited by tourists and long-te rm visitors. Many make multiple stops during their stay in Costa Rica visiting a va riety of beaches on both coasts. Foreign students in the area often take advantage of th eir weekends and make short excursions to different parts of the country. Finally, some students are purposely moved between different locations to allow them a more di verse experience while in Costa Rica. For example, the culture on the Caribbean side near Limon is English-speaking and has a more Jamaican feel than the Pacific coast. In addition, some students wish to visit the hot springs and volcanoes, while others prefer the beaches for surfing, fishing, or scuba diving. Costa Ricas diversit y and relatively small size en courages travel within the country to different ecosystems, whic h offer various adventure activities.

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93 RESEARCH OBJECTIVE 3: Assess tourists perceptions of HIV risk especially associated with changing behavior while on vacation These data come specifically from thr ee focus groups that were conducted with tourists and students visiting th e area. Some respondents were new to the area and others consider themselves residents or long-term tourists who have no specific departure date and are working in the area, either in tourism or in the schools. Additionally, data from in-depth interviews with long-term tourists and students were conducted to gain a better understanding of individual perceptions. Vacation Mode and Latin Lovers Most respondents noted the change of behavior that many people undergo while on vacation termed vacation-mode (see a bove discussion). Additionally, cultural stereotypes may facilitate some risky behaviors. As previously mentioned, foreign women are considered easy by local standards. Therefore, local men are under the impression that casual sex is easier with tourists and therefore make more of an effort or be more aggressive with foreigners. Many respondents, both local men and women, mentioned that foreign women are more liber al. Additionally, foreign women have the stereotype of local men being Latin lovers. The idea of Costa Rican men being exotic and better lovers than men from other count ries can also lead American women to be more curious about Costa Rican men and lead to casual sexual encounters out of that curiosity and vacation mentality. One respondent explained her experience, Yeah, when I came back from my vacation I told all my friends I had a two week romance with a Latin guy. They all said, I would trade EVERY sexual experience of my life for two weeks with a Latin guy, in paradise, you know?

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94 Female respondents perceived Costa Rican men as particularly attractive, especially when compared to other Latinos they have met in their travels. Costa Rica is one of the wealthier countries in Latin America, and Monteverde has a stable economy with regular tourism a nd coffee exports. Moreover, Costa Rica has social health care for all residents. Therefore, it is not surprising to find that local men are healthier, and possibl y better groomed than men in poorer communities. One respondent explained, You know you travel to othe r countries in Central and South America where [there] is a much larger line of poverty and you dont feel that as much here. E ven the [men] th at dont have a lot of money they still take a lot of time to take care of themselves because they dont have muchso they take good care of what they have. They have a lot of self respect and stuff going on, and thats really really attractive. Another female respondent stated: I mean obviously they [Costa Rica n men] arent ALL full of self respect but theres definitely a presentation much more so than in Nicaragua or Guatemala, Mexico, Panama or Colombia, or wherever, you know? Much more so and thats really attractive, it feels safer, it feels like you are taking less of a risk, you know? The riskiness of these sexual encounters for Americans is attributed to multiple factors. First, condoms are not available in the evenings. American s are accustomed to condoms being available at all hours (in bars, grocery stores, gas stations, etc) and may not realize that they are not available in M onteverde late in the evenings until they are already engaged in risky behavior. Additionally, many respondents mentioned the fact that local men do not carry condoms with them. Therefore, if foreign women expect men

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95 to be prepared, as they often are in the Unite d States, they will be surprised to discover that Costa Rican men are not carrying condoms. Long-term visitors identified increased cons umption of alcohol as directly related to clouded judgment leading to greater in cidence of casual, un protected sex. Many respondents recognized the fact that drinking increases consid erably while on vacation. The drinking age in Costa Rica is 18; howev er, participant observation and interviews revealed that for tourists this law is not en forced at local bars a nd stores. Therefore, students or visitors who are underage stil l have access to alcoholic beverages. Respondents felt that many students who are unde rage have little experience drinking and therefore noted an increased likelihood of them abusing alcohol and becoming intoxicated. I would say there is more casual sex with students than anyone else because of the length of time they are here, as well as their age. When a student comes and they are just out of high school they are more likely to act a little crazy, lik e flash their boobs in a bar or a public place, because they have less experience away from mom and dad and are more likel y to cut loose because they are away. They are also feeling le ss responsible for their actions and are not recognizable or dont feel accounta ble for their decisions, therefore, they ma ke poor decisions, most likely involving a [Costa Rican] in their 20s. Respondents also noted that the drinks in Monteverde are cheape r than they are in the United States and therefore may lead some tourists to drink more. When you are a tourist you save money to go blow on having fun, like so you go to the bar and you re not going to care if you have to spend like whatever, you know? Yeah, so you drink four of them [drinks] rather than like one, or eight instead of four, you know, whatever.

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Some respondents felt that there is a language barrier that may be difficult to overcome in relations between foreign women and local men. A number of local men speak limited English and may find themselves with foreign women who are unable to speak Spanish. This might be a major obstacle in terms of condom negotiation and addressing any sensitive sexual issues. Interestingly, the women interviewed agreed that communication was NOT much of an issue while the men interviewed were more likely to identify it as a barrier. 96 Figure 8: Sex and Freedom Mural Finally, the nightlife environment in Monteverde is conducive to initiating relationships between locals and tourists. In particular, respondents, both local and visiting, identified one bar in the area as a notorious place for local men to try and pick up visiting women. There is a notable lack of nightlife in the area so the majority of visitors and locals congregate at one particular bar. At the entrance to the bar, there is a piece of art, which has symbols of men, and women scattered throughout insinuating a variety of possible sexual combinations. For example, in one quadrant, there are two male symbols, in another there is just a male and female, and in yet another there is a group of male and female symbols. Above and below the depiction are the words sex and freedom. The scene inside the bar is typical of U.S. bars. However, respondents noted that there is a

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97 variety of music played shifting between popular American music and local dance music. Respondents, especially women, mentioned the aggressiveness of local men while in the bar. They gave examples of various pi ck up lines used. In addition, many women explained that being asked to dance by local men was very common. Many of the visiting women are not familiar with local da nces such as the salsa and the cumbia; however, local men would offer to teach them the dances. It was not uncommon to see local men and visiting women dancing provocatively. In addition, participant observation confirmed that many local men esco rted visiting women away from the bar at the end of the evening. Unfortunately, this type of environmen t may breed sexual assaults that go unreported. There was one known incident during the initial phases of the project when a foreign woman who was under the influence of alcohol and was atta cked by a local. However, the victim did not want to re port the attempted assault because she was embarrassed about putting herself in such a compromising position. Furthermore, she feared repercussions from the academic program in which she was participating. Finally, she was not aware of local law and protocol which intimidated her and prevented her from reporting the incident. This may be a common problem in the area, however, no interviews or discussions made direct statements concerning sexual assault. RESEARCH OBJECTIVE 4: to understand th e level of knowledge and community satisfaction with existing education and prevention activities HIV and HIV Testing Respondents had different perceptions a bout the extent of HIV in the local population. Some people felt that the rates were extraordinarily high quoting numbers of

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98 incidence as high as 500 cases. Others felt that there were only a few cases, which were public knowledge. Several stated that they did not want to know about the actual incidence of HIV in the community. There st ill exists strong stigma in Monteverde and many feel that if someone in the community contracted HIV they would be outcast out of fear. Those within the community did identif y married local women as being at risk for HIV. Women felt that there was risk when their partners were unfaithful and possibly infecting them without their know ledge. As one woman stated, There are many women who could be in fected and they dont know it because their partners are able to ha ve sexual relationships out side of their marriage. The majority felt that an increase in HIV wa s inevitable in all segments of the population because of the increase in casual sex, lack of adult supervision, and inadequate education. One respondent explained, [An increase in HIV] is going to be very serious in Monteverde. You are going to see an increase until the young people star t to be educated then the level would be able to fall signific antly. BUT, now it is growing more and more. Another interviewee added, People are starting very young and are already beginning to play with sex. All they want is bodily pleasure. The problem is this: a lot of people are leaving their kids and going out so their kids are gr owing up bad because the parents arent involved in their lives. The following generations are going to suffer because of the behavior of people today. Now ther e are young people that are involving themselves in drugs, sex,. etc. As described in Chapter 3, HIV testing is available in Monteverde, but few people actually take advantage of it because they f ear stigmatization, or discrimination should their results come back positive. Some si mply prefer not to know, because not knowing is better than finding out you are HIV positive. One informant said, I would rather jump off a bridge than live with HIVbecause people with HIV dont really have a life

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99 anyway. Others report that they feel a nd look healthy therefore being tested is not necessary. In addition, there is very lit tle privacy within the community because everyone knows everyone else. If someone went to be test ed, it is likely that somebody would see them or hear about it resu lting in rumors being spread. [getting tested for HIV] is not something the people here are doing. The people are not going to stand in line at the window for AIDS tests where all the world can see you. All the people are going to automatically believe that you have AIDS. People are afraid of what other will say, they need something more private. There are some misconceptions about the actual HIV test. For example, one respondent felt test results were often inconsistent resu lting in numerous false positives or false negatives, and therefore the te st itself causes too much anxiety for some community members. Current Sex Education Overall, there is very little done to ra ise awareness about STI/HIV or to provide prevention messages in places where tourists an d locals socialize. The great majority of the tourists in our project reported that they had not seen any flyers, pamphlets or any other educational material in any of the pl aces where they socialize with locals, and where sexual relations are eas ily initiated. Only a few respondents reported hearing commercials for condoms on the radio, but no ot her educational materials of significance on either the T.V. or the radio. This is an alarming fact given th at a great proportion of visitors/tourists in our study reported that th ey had casual sex with Costa Ricans. While the likelihood of casual sex increas es with the length of the st ay in the country, casual sex was reported among both short term and longterm visitors. One respondent who works in tourism explained,

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100 Now there is much more sex in Monteverde and more with the young people. The majority of those [locals having casual sex] are with those who come to visit. There are so many young local men [havi ng casual sex], and why? Because more than anything there are foreign women tr aveling to [Monteverde] and the local men know how to romance them saying, your hair is so prettyyour eyes are so beautifulthose pants look so cool. In addition, the foreign women hear that local men are hot [and good at sex] and VERY friendly. Then when the foreign women leave and get to the United States they talk about the local men and how they found local men very hot and ver y good at everything including sex and then those girls come with knowledge of local men and want to try it out for themselves. There is a major gap in the provision of sex education to young people in the area. Our data indicate that, while some adolescents have appropriate knowledge of STIs/HIV, the great majority exhibit major deficits. For example, in the high school discussions students asked a wide range of questions. Many students lacked basic knowledge about HIV and STI transmission a nd prevention strategies. Other students had more specific questions suggesting that they had some level of knowledge. Only one of the three high schools in th e area has a permanent sex educator, while the other two do not offer any such instruction in their curriculum School directors mentioned the difficulty in developing a comprehensive program because of stigma that still exists in the community. They mentioned difficulties in hiring local teachers who would be willing to broach the subject in a complete, continuous manner. Parents, teachers, and students all stressed the need for comprehensive education that addresses not only basic sexual matters, but that also stresses STI/HIV and pregnancy prevention. It was also suggested that education be gin early and demonstrate some form of continuity. Many complained of the current education being disjointed with students being taught sex education only once or twice in all their middle and high school years combined. Educating children early and contin uously revisiting the topic as they mature

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101 and develop was very important to both a dults and children. The high schools students who participated in our focus groups especially emphasized the need to adapt an interactive format of education that actively invo lves the students in the learning process. Some respondents did feel that there was adequate education, but in their opinion, the real problem was that young people feel in vincible, and will therefore continue to engage in risky sexual activities. Nevertheless, these re spondents also provided some suggestions for improving HIV/STI education. Respondents felt vivid visual materials showing the initial stages of HIV infections when an individual appears healthy to their ultimate painful death might be effective. Several community members felt a presentation or discussion by someone who had contracted HIV would also be effective. Another innovative suggestion was using th e popular Latin American media of the telenovela, which is similar to the U.S. so ap opera, as a means of representing HIV to local populations possibly by having a character contract the disease. In addition, all groups felt that condoms need to be made mo re available and suggested the need to install condom-dispending mach ines in the bathrooms or other more conspicuous locations There is also a lack of knowledge among the older population, and parents in particular. An informal conversation with a local father revealed that he had false information about condom effectiveness. He was under the impression that condoms were not effective because the virus is so small it can pass right through. Respondents mentioned that education needs to also ta rget parents so they can openly communicate with their children. Respondents felt that co mmunication between parents and children needs to improve on all levels, and this ch ange would encourage a more open discussion

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102 about sex, sexuality, and safe sex practices. The more sex is discussed the less taboo it becomes. One respondent explained that it would be easier to buy condoms or talk about safe sex if it became a normal topic of discussion. Lack of Activities for Young People High school discussions revealed that the majority of young people are interacting regularly with tourists at local bars and d icotecas. They explai ned that there is not much to do in Monteverde at night other than frequent these bars. Participant observation confirmed these statements as many underage local s were regularly seen at bars at night. The laws prohibit minors, those under 18, from being in bars; howev er, there is little enforcement of these laws. Occasionally th e local police would enter bars and check identifications making local minors leave the es tablishment. However, police were never seen asking tourists for identification. Moreover, young people who are underage have access to alcohol. One local st udent jokingly said alcohol is easier to come across than water in Monteverde. The majority of respondents recommended that some type of program be developed to engage young people to participate in activities other than going to bars to drink, dance, and use drugs. Many suggested developing centers for young people where they could play sports, learn art techniques, la nguage courses, and drama classes. In fact, the co-principal investigator on this project was concerned with the lack of activities for young people and therefore teamed up with a young local Costa Rican to develop a meeting place called CLAVE, which is an acronym for Culture, Language, Arts, Vision, Energy. This cultural center provides a place for young people to get together and

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103 partake in various activities in cluding dance lessons, language courses, music classes, and art projects. RESEARCH OBJECTIVE 5: To identify new strategies for educating and disseminating information about STI infect ions to both tourists and locals. Targeted Education Many respondents from different segments of the community also mentioned the need to develop education/prev ention strategies that target groups other than the youth. Special emphasis was given to the need to target single men and women as well as married couples. This latter group was believed to be at high risk due to the reported high rates of marital infideli ty. Respondents felt that anyon e working in tourism should be targeted with HIV education materials beca use they were more likely to have casual sex with foreigners. For example, naturalist guides, Sky Trek guides, hotel receptionists, waiters/waitresses, and bartenders were iden tified as a particularly high-risk group. The majority of respondents did not think local wome n were at risk of c ontracting STIs from tourists, but rather from their local partners. One local nurse reported, Now there appear[to be]? a lot of housew ives with various sexually transmitted diseases because the husband is behaving badly. We have a lot of cases like that where the husband is infected and sleeping with other women and bringing infections to his wife who is faithful at home. Foreign long-term tourists, especially wome n under 30 years of age, are considered the highest risk and in need of a reminder a bout STI prevention. Suggestions for reaching tourists and foreign students with HIV edu cation materials include running sex education and HIV prevention seminars through the in stitution sponsoring their trip, printing materials in guidebooks such as the Lonely Planet, and passing out free condoms. Other

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104 groups that were identified as needing special educati on are migrant farm workers (Nicaraguans, in particular), and those w ho do not access the public system of health care. Like all the other sectors of th e community, government and business representatives were very aware of the po ssible impact of tourism on the spread of STIs/HIV and expressed their strong support fo r education campaigns that target not only locals but also tourists. Contra ry to what we originally thou ght, those directly involved in the tourism industry were not concerned about the possible negative impact that overt HIV prevention campaigns could have on thei r business (that is, provide an image of Monteverde as having a serious HIV problem, thus scaring potential tourists). Rather, they all stressed the desirability of offe ring education through different channels to protect the health of both Costa Ricans and foreigners. Sex Education and Religious Considerations Not surprisingly, representatives from the religious sector were somewhat more reserved in their endorsement of STI/HIV education. The members of the Evangelical church who were interviewed expressed their support for abstinence only messages, but did not directly voice their disapproval of a ny other education efforts. Although we were not able to conduct formal inte rviews with leaders of the Ca tholic Church, data obtained from a participant in a pre-marital couns eling sessions show that the Church is incorporating a discussion of condoms, if onl y as a means of birt h control. In our interviews with parents and other members of the community, there was overall support for sex education that moves away from the abstinence-only message. Interestingly, this support was found regardless of the religious affiliation of the parents interviewed.

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105 Chapter 5: Conclusions This project attempts to understand comm unity perceptions regarding the impact of tourism on changing local behavior, especial ly increased risk beha vior associated with HIV and STI transmission. Many of the findings were not surprising and were supported by previous research in sim ilar contexts. For example, the connection between tourism and changing behavior, partic ularly among young people worki ng directly with tourists, is a commonly identified phenomenon (Forsythe et al 1998; Skoczen 2001; Taylor 2001). The increase in high risk sexual activi ties in Monteverde, especially resulting from an increase in drug and alcohol use ti ed to the party scene have also been identified in many other tourism areas and directly linked to HI V and STI transmission (Josiam et al 1998; McKercher and Baur 2003; Pruitt and La Font 1995). Also, the idea of the exotic other whereby t ourists and locals share a mutu al fascination and attraction to each other has been cited as a reason for increased casual sexual liaisons. These encounters are particularly risky because of different cultural nor ms and expectations along with the possibility of language barr iers preventing condo m negotiation (Herold et al 2001; McKercher and Baur 2003; Meis h 1995; Pruitt and La Font 1995). So far, Costa Rica has not demonstrat ed particularly high levels of HIV prevalence. However, traditi onal ideas of machismo (whi ch prevent men from carrying condoms or accessing resources and materials from the local clinic), in conjunction with limited access to condoms and sex education th at lacks continuity places young locals in

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106 a particularly vulnerable situation as they attempt to negotiate the new economic and social environment emerging in this once rural, quiet community. This research suggests numerous emerging topics concerning the impact of tourism and HIV that need more in-depth study. Many of these issues are the direct result of increasing globalization, which has facilitated an explosion in population movement. For example, the new demographic group of single, young, female students and volunteers who live with families for an extended period is of particular concern because they are most likely to develop rela tionships with locals. These relationships place both local men and foreign women at risk because, despite womens knowledge about HIV and STIs, they often become lax in their safe sex practices and change their normally careful behavior resulti ng in decreased condom use. Moreover, growth in tourism leads to profound changes in communities as their economies shift and adjust to this increase fl ow of capital. For example, tourism in Monteverde has resulted in the movement of some young locals into the area, but more significantly shown a shift of young people out of schools and into the tourist industry. The importance of economic growth and the earning power of young people in this area supersede the desire for education, which sp ecifically disrupts sex education. Many residents noted that as young people become more economically independent and more integrated into the tourist and nightlife scene, they lose their morals and become active in high risk activities that could easily result in the spread of STIs. In addition, parents are engaging more in the tourist industry resulting in less child supervision. Many young people, when left to their own devices and with few recreational alternatives, fi nd themselves engaging in activities revolving around the

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107 nightlife perpetuated by the to urist industry, which includes alcohol and drug use as well as casual sexual relationships. Moreover, condoms are not easily accessible to either locals or tourists as stores selling condoms close early. These tre nds together with the fact that there is a lack of adequate education and prev ention materials, especially targeting young people, can easily facilitate an explosion of HIV and STIs. Another surprising finding is the idea of romance tourism that has been given limited attention thus far (Mei sch 1995; Pruitt and La F ont 1995). Many local men are involved in serial monogamy whereby they develop relationships with long-term tourists for the duration of their stay (sometim es lasting months at a time), and then begin new relationships as soon as their previous part ners leave the area. This is of concern as many of the locals, and the foreign women involved, perceive these re lationships as trust relationships and therefore usi ng a condom is not necessary. Th is trend is different from that reported in research that examines local men using foreign women for money, passports, or other forms of economic gain (Forsythe et al 1998; Herold et al 2001), because the local men and tourist women in Monteverde, for the most part, do not seem concerned with issues of money or passports The women seem involved for reasons of romance and the men for sexual adventure. This dynamic often leads to increased risky sexual behavior due to the dangerous combination of negative ma le attitudes toward condom use coupled with female perceptions of being in a trusting and exclusive relationship. This thesis has examined the va rious trends and attit udes that have emerged in Monteverde, as tourism has become the essential industry. Unfortunately, these current attitudes and behaviors observed a nd reported can easily culminate into a

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108 disastrous HIV or STI epidemic if they are not addressed quickly. Fortunately, current rates appear to be low, and education is a proven mechanism for preventing HIV. Recommendations Currently, there is not an extraordinarily hi gh reported rate of HIV in Costa Rica. In fact, compared to other Latin American count ries the rates seem rather low. However, this apparent trend may not be accurate as reporting and testing is limited within the country in general and very low in the P untarenas region in pa rticular. However, historically HIV transmission has been asso ciated with tourism and migration, which suggests a potential explosion of the dis ease in Costa Rica. All factors including traditional values of machismo, tourism, early onset of sexual activity, limited education, and limited access to resources including condoms suggests the potential for a terrible situation to develop in the region. Addressing the potential spread of HIV through prevention as opposed to treatment for the dis ease is the most cost efficient and easiest avenue for halting the spread of HIV. R ecommendations stemming from this project are geared toward the following interested parties in Monteverde: health care workers in the clinic, educators, people dea ling directly with tourists (Chamber of Commerce), and local institutions working wi th long-term visitors. Health Care Workers Health care workers in Monteverde shoul d be more proactive in educating about STI transmission and prevention. They shoul d employ an outreach program that focuses on educating men away from the clinic setting since the major ity of men tend to shy away from visiting the clinic on a regular basis. Moreover, there seems to be a consensus among those interviewed that going to the clinic for condoms is too time intensive

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109 because it requires a prescription. Therefor e, a better system fo r distributing condoms needs to be developed. In addition, many resi dents complained about the quality of the condoms the clinic distributes. It is recommended that the clinic upgrade their condom selection to include condoms that are pref erred by locals. Finally, many residents avoided being tested because of the lack of anonymity they associated with using the local clinic. Clinicians therefore need to de velop a system that is will ensure privacy of all patients. Educators A major criticism noted by many respondents is the lack of consistency in the sex education programs in Monteverde. It would be beneficial if all the schools, both public and private, developed and approved a mandato ry curriculum of study that began at an early age and continued through high school. Students should be taught about all aspects of sexual relations including biology, sexually transmitted infections, condom negotiation techniques, and other prevention technique s including abstinence and condom use. School clinics should be an avenue whereby students can anonymously seek information, counseling, and condoms. Comm unity involvement in the cr eation of this curriculum would be advantageous because it ensures a cu lturally relevant a pproach to education while including parents and community lead ers who can then reiterate the knowledge students gain at school in the home environm ent as well. Furthermore, presentations, classes, or projects that are more interactiv e such as poster or writing competitions on the subject of HIV and STIs, role plays or dram as, or creating their ow n telenovelas (popular Spanish soap operas), jingles, or commercials would help students feel less of a stigma associated with STIs, thereby encouraging mo re open and honest discussions with parents

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110 and teachers. Finally, bringing in HIV positive speakers who can give their life histories and explain the impact of the disease on their everyday lives will help make the reality of HIV more evident. Tourism Sector Those working in tourism especially owne rs of local backpacker-style hotels should make HIV materials and condoms accessi ble to tourists. There was little to no opposition from the community and local touris ts to aggressive, visible HIV prevention campaigns. Therefore, during the high season local organizations should engage in these types of education campaigns focused on touris ts and visitors in the area. Moreover, there are numerous local groups for those working in tourism, such as the Wilderness Guide Association. These groups should provi de HIV education to incoming members as well as continuing education for established members. In addition, tourist companies, such as Canopy Tour Operators, should pr ovide some education for their new guides during training. This would be particularly useful because many of these new employees are young men who are no longer in school and therefore not receiving any sex education. In addition, they were identified as one of the more at risk groups because of their age and direct contact with adventure tourists. Local Institutions The local institutions that host long-term students should incorporate a discussion of appropriate behavior and sa fe sex practices into their st udent orientation sessions and in their handouts. Many students are aware of safe sex practices; however, a simple reminder may be effective in encouraging them to be prepared and aware of the potential risk situations that exist in the area. Furthermore, during meetings with potential

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111 homestay families these institutions s hould address the need for open and honest discussions concerning appropria te behavior and family exp ectations with the students who are assigned to their homes. Instituti ng an evaluation system whereby homestay families are able to express concern or report inappropriate behavior observed back to the sponsoring institution may help curb risk behavior. Suggestions for Future Research This was a short-term pilot study meant to grasp a basic understanding of the way in which tourism is influencing local beha vior. The findings are significant, and disturbing, enough to warrant a more in-depth study before HIV significantly affects the community of Monteverde. Moreover, as in ternational travel increases, more rural communities that have had limited contact with international travelers will face similar economic and social changes. Understandi ng how and why the behavior of young people is changing may serve to prevent an HIV explosion in currently healthy communities. Dr. Nancy Romero-Daza is currently working on developing a larger grant to continue this work in Monteverde. As a first ste p, she secured funding from the Globalization and Research Center at the University of S outh Florida to develop awareness materials specifically targeting those sub-groups cons idered at high risk including; long term visitors, youth, and men. This pilot intervention program was conducted from November 2004 to April 2005 and included partic ipatory action research with forty rural women to culturally appropriate HIV preven tion materials to be distributed throughout the community. For example, in one town the participants developed address/phone books, especially geared to young women. In another community, they created key chains with HIV messages for both men a nd women. In the third town, women

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112 developed a 12-page calendar meant to educate the whole family. Finally, in Monteverde they developed two posters sp ecifically geared to tourist (especially young women) emphasizing the importance of condom use Specifically, it would be worth undertaki ng a more in-depth study of the reasons foreign women who travel are more lax in their safe sex practices. In particular, exploring the idea of romance tourism which thus far has had limited study might be insightful and beneficial in cu rbing the spread of HIV and ST Is. In addition, it would be fruitful to examine the ways in which an in flux of female tourists who regularly engage in sexual relationships with local men influe nces the behavior and ideas of local women concerning sex and relationships. Finally, a mo re in-depth study of local men working in tourism and the affect casual sexual liais ons with tourists ha s on their ideology of marriage, trust relationships, and safe se x, with both local women and foreigners Contributions to Theory, Applied Anthropology, and Public Health Critical medical anthropology provides a us eful theoretical framework for this thesis because it effectively ties in larger global forces, which in this case would include globalization and capitalism, to their impacts at the community level, which in this case is risk behavior between inte rnational tourists and young locals in the community of Monteverde. Globalization has facilitated the movement of people across the world (Drager et al 2001). As technology and innovation increase, the price of travel becomes more reasonable. Today, people are able to travel to places that were once outside their sphere of possibility either due to such constraints as travel costs or lack of efficient transportation. More and more young people, with a spirit of adventure, are taking advantage of these international travel expe riences. Popular destinations now include

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113 places in Africa, Asia, the Middle East, and Latin America that are economically considered third world or developing. In an effort to take advantage of the tourist industry, many national governments are support ing and advertising their countries as places of beauty and adventure. Costa Rica is a very popular tourist destination that has been highly successful in promoting eco-tou rism (World Tourism Organization 2005). Unfortunately, they have also encouraged sex tourism, which has resulted in the proliferation of the child sexual exploita tion industry (U.S. State Department 2004b; Write 2004). Tourism has become one of the most important economic pursuits in Costa Rica and many communities, such as Montever de, have become dependent on tourism for survival. This dependency results in an ine quitable distribution of power between locals and tourists (Taylor 2001). How does Montev erde illustrate this dependency theory? One example to illustrate how these forces are at work in Monteverde would be the issues of the homestay experience. Throughout this research, community members identified the homestay experience as a key element in increasing risky sexual behavior between local youths and foreign women, which many fe lt results in the degradation of family values and young peoples morals. If this is the case, then why do families in Monteverde continue to invite these students into their homes ? In this case, the economic gain in participating in the homestay experience is substantial and families are willing to take in students at the risk of moral de gradation and HIV transmission because they have become reliant on the income that these homestays produce. Another important question to ask is why sexual risk-taking occurs in Monteverde? There are numer ous reasons that were identif ied throughout this thesis, and it is prudent to analyze these local manifest ations by looking at th e larger macro-level

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114 processes at work to influence community-l evel and personal deci sionmaking. Clearly, the phenomenon of globalization results in sign ificant economic and social change, which is influenced by historical processes. Farme rs (2003) discussion of structural violence is important in understanding contemporary Mont everde, and who is at risk for HIV, and why. Historical structures sust aining machista attitudes conti nue to exist in Costa Rica. Therefore, it is more common to find men working in tourism and women maintaining their traditional roles in the domestic sphere However, this trend is slowly changing possibly because of western influence and idea s of feminism and female independence to which local women are exposed because of th e increase in young, independent females to the area. Nevertheless, in general, men are more in contact with tourists. In addition, men are permitted to be more sexually aggressi ve and the idea of having multiple sexual partners is more acceptable for local men than for local women. Finally, machista attitude suggests that men are untouchable, indestructible and dem onstrate high levels of virility. Therefore, men tend not to perceive HIV infection as a real possibility. These ideologies about gender roles and masculin ity clearly create an environment that increases susceptibility to HI V transmission. Furthermore, s hould the virus take root in Monteverde, the feminization of AIDS (which refers to the dispr oportionate growth in AIDS among women compared to men and is due in large part to gender inequality, poverty and marginalization) is a likely outcome due to persistent gender inequality in Latin America. This means that local wome n, particularly housewives, can be expected to be at high risk for contracting the infec tion from unfaithful husba nd or boyfriends, as is being seen in other HI V affected populations.

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115 Finally, an examination of the polit ical environment suggests reasons for increasing tourism and in turn increasing HIV risk behaviors in Mont everde. First, the stable political scene in Costa Rica makes trav elers feel at ease and comfortable traveling to and within Costa Rica. The disbanding of the army and relatively consistent, agreeable relations between the Costa Rican and U.S. governments may also encourage travel. This political environment in conjunction with Costa Ricas insufficient sex education and HIV prevention and testing policies have cr eated a space whereby locals are not fully educated but constantly exposed to possible routes of infection. Cl early, the critical medical anthropology perspective is valuable as it allows an examination of the political and economic influence at the international, national, and local levels and how this shapes community and individual level behaviors and ideals, and in this case, resulting in a scenario ripe for the transmission and explosion of HIV and STIs. The purpose of applied anthropology is best described by the past president of the Society for Applied Anthropology, Dr. Linda Whiteford when she wrote that applied anthropologists are those who use the appl ication of scientific principles for the improvement of peoples lives and the resolu tion of human problems (Whiteford 2004: 408). Anthropology is well equipped for such an undertaking because of its unique blend of qualitative and quantitative methodology grounde d in strong theoretical orientations. Applied medical anthropology seeks to gain kn owledge of human behavior and decisionmaking which includes an investigation into local underlying ideologies, both conscious and unconscious, for the ultimate purpose of understanding health, health beliefs, wellness, and healing. These data can be used to guide policy, practice, education, prevention, and intervention to improve human health and wellness. This project was

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116 Figure 9. Guillermo Murillos Community Talk on HIV/AIDS Figure 10. HIV/AIDS Prevention Banner I designed with the purpose of engaging in anthropological fieldwork to understand HIV and STI risk and ultimately design an intervention to protect the health of all impacted groups. Therefore, the collective team was able to identify risk groups and creatively consider ways to educate them with specific materials and techniques. For this reason, following preliminary analysis while in the field we designed a public health HIV prevention campaign with numerous components individualized to address different risk groups with culturally relevant and acceptable materials and resources. Using these methodologies to gather, analyze, and interpret data with the ultimate goal being to resolve potential problems or prevent potential threats from harming a community is the goal, the essence of applied anthropology. Following the main phase of data collection the research team decided to undertake various activities in an effort to become involved in prevention and education. The team recruited Guillermo Murillo, a Costa Rican HIV positive activist and educator from San Jose to visit

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Figure 11. HIV/AIDS Prevention Banner II Monteverde during the first week of December to commemorate World AIDS Day (December 1 st ). Guillermo Murillo is assistant director of The Agua Buena Human Rights Association ( ) which is an activist organization focusing on securing health benefits including antiretrovirals for people living with HIV throughout Latin America. During his visit to Monteverde, Guillermo Murillo, gave one community talk and several informational sessions in the local high schools. He addressed a variety of issues including routes of transmission, ways to prevent transmission, and commonly held myths. He also included a demonstration of how to properly use a condom. He concluded his talks with a question and answer session. Additionally, the team designed and posted educational banners in a public place in the community. The banners had a variety of messages including the following information posted on different days: Day 1: HIV/AIDS: There are no symptoms, it results in death, take the test, there is treatment Day 2: Prevention: Abstinence, using a latex condom correctly before contact. Get tested! Day 3: You cannot contract HIV/AIDS through casual contact. Yes, you can hug, share food, swim, kiss and touch someone infected. 117

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Day 4: You can prevent HIV/AIDS! The 118 Figure 12. Condom Distribution Night virus can be transmitted by sex and injection Drug use. It lowers the bodys defenses causing susceptibility to other diseases. THERE IS NO CURE! Day 5: Drugs + Alcohol = Casual sex without protection. Take care of yourself!!! Figure 13. How to Use a Condom Flyer Additionally, many young community members helped distribute free condoms during the weekend of Guillermo Murillos visit. T-shirts were designed that read on the front, What are you able to get for free? HIV/AIDS, Syphilis, Gonorrhea, Herpes, Chlamydia, or In addition, on the back read, a condom, ask me for one. Over five hundred condoms of a variety of flavors, gels, and female condoms were distributed along with a small handout that contained information on how to properly use a condom with photos on one side, and facts about HIV/AIDS transmission, prevention, and rates in Costa Rica on

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119 the other. There were a noticeable number of local women asking for condoms during the weekend distribution campaign. Overall co mmunity support for the project was very positive. We printed more shirts than were needed; however, locals requested the left over shirts because they felt the message wa s important. There were no complaints received from any of the local religious institutions. Moreover, several community members requested the education and condom campaign be repeated annually. Similarly, the community identified long-term female visitors as at a disproportionately high risk group and asked for education material aimed at this demographic. Therefore, Cristina Calderon, a volunteer on the project who has extensive HIV education experience working with Span ish-speaking populations in the Washington D.C. area, and I developed an educati onal PowerPoint and held a group discussion during the orientation at the Monteverde Institute for stude nts involved in an eight-week biology course. This session included a disc ussion of our results and recommendations for appropriate behavior while in Montever de. Feedback was requested following the presentation. The students found the presentati on insightful and a valuable component to their overall orientation. Th e only additional recommendation they made was to include a handout with Spanish phrases that would facilitate a disc ussion of safe sex practices with a non-English speaker. Finally, a community health facilitator and I developed and performed a drama during the annual orientation meetings for new homestay families in the three communities of Monteverde, Santa Elena, a nd San Luis. The drama demonstrated a generalized scenario of the nightlife of Monteverde and provided examples of how homestay families can discuss issues of safe sex and proper behavior with students.

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120 Following the drama information printed in Spanish was distributed to the families with the suggestion that they use these materials to initiate discussions with the students who stay in their homes. Homest ay families recognized the need for addressing the issue of casual sex between students and locals. Seve ral women asked to be a part of the study because of experiences or knowledge pertai ning to the subject. Clearly, the people of Monteverde are aware of the impending negativ e health consequences that result from risky sexual behavior, and reali ze that now is the time to act to preserve their health and well-being. This thesis should be used to addres s some of their concerns and help mold or influence future public health prevention efforts.

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136 Appendices

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137 Appendix A Informed Consent (English) Name of Project: Perceptions of Sexually Transmitted Infections (STIs) in the community of Monteverde, Costa Rica This is an exploratory project to determine the perceptions of STIs, including HIV/AIDS, in the community of Monteverde, Costa Rica. We are specifically interested in what the people think of the impact tourism can have on the transmission of these infections. The information that you provide will help to dete rmine how serious the problem of HIV is in the community and what needs to be done to fight it. If you do not mind, we would like to record your responses for data analysis purposes. Your answers will be maintained in complete anonymity and we will not use your name or any other information that could identify you in any reports or presentations. This consent form will be filed separately and locked in the Institute of Monteverde. The only people who have access to this information are the investigators on the projec t. The tapes will be destroyed three years after the project is finished. Your participation in this project does not have any physical or psychological risk. Please remember that we will never ask about your personal behavior only your ideas and opinions on the theme. We expect that the interview will last between 45 minutes or an hour dependi ng on how much information you would like to share. Your decision to participate in this interv iew is completely voluntary. You have the freedom to participate or not participate. You can suspend your participation at any moment. If you decide not to participate or to suspend your partic ipation, there will be no consequence. You can refuse to answer any question you feel is inappropriate or you can terminate the interview at any time. This project is being sponsored by the Universi ty of South Florida, under the direction of Nancy Romero-Daza, telephone number in the United States (813) 974-1205. If you have any questions about the project, please contact Sofia Klempner at the Institute of Monteverde, telephone number 645-5053, ext 111 or 645-5365 or 645-5219. ____ I certify that I have read the information about the project and that I am willing to participate. ____ I give permission for the interview to be recorded. ____________________________ ____________________________ __________ Name Signature Date Affirmation of the Investigator I have carefully explained to the participant the meaning of the above document. I affirm that to my best understanding, the signed participant understands the nature, expectations, risks and benefits associated with participating in this study. ____________________________ __________

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Appendix B Open-ended Interview Guide (Spanish) QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. PROYECTO ETS Gua de Entrevista Semi-Estructurada Gracias por acceder a hablar con nosotros. Estamos entrevistando a varias personas de la comunidad para saber sus percepciones acerca del impacto que el turismo tiene en la salud en general en Monteverde y especficamente en la transmisin de enfermedades sexuales incluyendo el VIH/SIDA. La informacin que Usted nos brinde nos ayudar a determinar que tan serio es el problema de VIH en la comunidad y que se debe hacer para prevenirlo. Sus respuestas sern completamente annimas y no usaremos su nombre ni ninguna otra informacin que lo pueda identificar en nuestros reportes o presentaciones. Por favor recuerde que puede rehusarse a contestar cualquier pregunta que considere inapropiada. INFORMACIN SOCIO-DEMOGRFICA: Primero voy a hacerle unas preguntas generales sobre Usted y su trabajo. 1. Qu edad tiene? 2. Dnde vive? 3. Cunto tiempo lleva viviendo en esta rea? 4. Cul fue su ultimo grando de estudio? 5. Cul es su ocupacin principal actual? 6. Cunto tiempo lleva en este trabajo? 7. Por favor describa su nivel de contacto/interaccin con turistas: 8. Con qu tipo de turistas se relaciona mas frecuentemente? Tambien, habia tenido o tienen estudiantes/voluntarios en su casa? (edad, sexo, tipo de turismo, etc.) 9. Segn su experiencia en el turismo, cmo ha cambiado el tipo de turista que llega a la zona en los ltimos 5 aos? PERCEPCIONES SOBRE EL IMPACTO DEL TURISMO: 138

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139 A ppendix B (Continued) Open-ended Interview Guide (Spanish) Ahora queremos saber lo que Ud. piensa sobre el impacto del turismo en la salud de las personas y la comunidad de Monteverde 10. Algunas personas piensan que el turismo trae cosas positivas para la salud general de la comunidad. Por lo que ha visto en Monteverde, qu piensa Ud. sobre eso? ( probe for specifics ) 11. Al mismo tiempo, se dice que el turismo puede afectar la salud de la comunidad de una manera negativa. Qu cree usted? ( probe for specifics ) 12. En muchos pases donde hay industria de turismo la gente se preocupa por el impacto que los turistas puedan tener en la trasmisin de enfermedades sexuales incluyendo el VIH. Usted qu cree acerca de esto? 13. En su opinin, qu impacto podran tene r los turistas en el comportamiento sexual de la gente que vive aqu? (probe for specifics: s exo casual, sexo con multiples personas, prostitucin, etc.) 14. Qu impacto piensa podran tener los turistas en el us o de drogas y alcohol aqu en Monteverde? 15. Qu efecto tendra estos usos de drogas y alcohol en el ri esgo de contraer enfermedades sexuales? 16. Si hay algn impacto del turismo en el comportamiento sexual o en el uso de drogas, cules son los grupos mas afectados? Porqu? 17. Cules son los menos afectados? Porqu? PERCEPCIONES SOBRE MEDIDAS QUE SE DEBE TOMAR 18. En su opinin, qu tan serio es el pr oblema del VIH/SIDA u otras enfermedades sexuales en Monteverde? 19. Qu tan serio cree que vaya a ser el problema en el futuro?

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140 A ppendix B (Continued) Open-ended Interview Guide (Spanish) 20. Qu se est haciendo en este momento para educar a la gente de Monteverde sobre las enfermedades sexuales y el VIH/SIDA? 21. En su opinin, qu tan adecuados son los programas que existen? 22. Si usted pudiera disear/modificar progr amas para jvenes como los hara? 23. Cmo hara para educar a las mujeres? 24. Cmo hara para educar a los hombres? 25. Qu se debe hacer para educar a los turistas? 26. Quin debe tomar la iniciativa para esto s programas? Quin debe pagar por esos programas? ( porqu estas son las mejores personas y/o instituciones) 27. Qu mas se debe hacer para hacerle fr ente a las enfermedades de transmisin sexual y el VIH/SIDA? 28. Por favor digame si hay algo mas que Uste d quisiera comentar sobre el tema de enfermedades sexuales o el HIV/SIDA en Monteverde Muchas gracias por su tiempo y la informacin que nos ha dado. Esperamos presentar estos datos en forma ge neral a personal de la clnica y otras personas interesadas a principios del prximo ao (febrero/marzo).

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141 Appendix C Focus Group Interview Guide (English) Thank you for agreeing to talk with us We are interviewing long-term visitors to the Monteverde area to find out what they think about the impact of tourism on the spread of HIV/AIDS. Please note that we will not ask you about your own sexual or drug-use behavior, but rather about what you have seen during your stay in the area. Your answers will help us determine the extent of the HIV problem in the region and what can be done at the community level. The information you provide will remain confidential, we will not use your name or any other identifying information in our reports. Please remember that you have the right to refuse to answ er any questions you consider inappropriate 1. How would you describe a typical Friday night in Monteverde to a friend back home who has never visited Costa Rica? 2. Do you think HIV/STDs are a serious problem in the region of Monteverde? Do you think there will be a problem in the future or how serious of a problem do you think it will be in the future? Why? 3. Many people believe that tourism plays a major role in the spread of HIV and other STDs. What do you think about that? Probe: vacation-mode. Probe: people say that tourists tend to have casual sex with locals. Based on what you have seen or heard when you go out, how true do you think this is in the Monteverde region? (probe fo r unprotected sex, multiple sexual partners, prostitution). 4. Which groups would be the most affected? Why? Probe: young, old, guides, gende r, taxi drivers, etc. 5. In your opinion, what impact, if any, coul d tourism have on the use of drugs and alcohol here in Monteverde? How could this impact the risk for HIV/STDs? Which groups would be the most affected? 6. Is there another way in which tourism might contribute to the spread of HIV/STDs? 7. Based on what you have seen in the co mmunity: bars, discos, schools, hotels, clinic, etc., how much do you think is being done to educate people about HIV or other STDs? Probe: posters, flyers, etc. 8. How effective do you think existing educational/ prevention programs are?

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142 Appendix C (Continued) Focus Group Interview Guide (English) 9. What is the most effective way to educate young people about HIV? Women? Men? Is there another group that you coul d identify which might be at a higher risk and might have a greater need for education? 10. How, When, Who should be responsible for local education? 11. Is there something that should be done to work with the tourists that come into Monteverde? Who should take the in itiative? Who should pay for such programs? 12. Is there anything else that should be done to confront the issue of HIV/STDs in this region? 13. Is there anything else that you would like to add concerning any of these issues? GRACIAS POR SU PARTICIPACION

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143 Appendix D Short-Term Visitor Survey Codigo _______ Entrevistador __________________ Fecha____________ Consent ______ Thank you for agreeing to talk to us. Your res ponses will help to inform a research project looking at local perceptions of STDs and HIV. We will not ask you about your personal behavior, but rather about your perceptions based on what you have seen or heard during your stay in Monteverde. We refer to Monteverde in this survey in a broad sense to include the various communities involved in tourism in this area. Your name or other identifying information will not be used when presenting results. This should take about 8 minutes.. A. Background Info 1. How old are you? ________ Code for gender _______ 2. Where are you from? _______________ 3. How long have you been in Monteverde? ________ days / weeks / months 4. Where else have you visited in Costa Ri ca on this trip? For how long were you in each location? 5. Where else do you intend to travel while in Costa Rica? And for how long do you intend to visit those locations? 6. Where are you staying? __ Local family __ Hotel __ Rented cabin or house B. Travel specific 1. Why did you come to Monteverde? __ Vacation __ Studies __ Other: __________________ 2. Who are you travelling with? ______________________________________ 3. How many times have you gone out to di scos or bars during your time here? ______ C. STD risk behaviors 1. Which places have you noticed tourists and Costa Ricans socializing the most together in Monteverde? __ Bars __ Discos __ Restaurants __ Local homes __ Other: ________________________________________

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144 Appendix D (Continued) Short-Term Visitor Survey 2. People say that tourists lik e to go out on dates with Cost a Ricans. How many tourists or foreign students do you know of who have dated a Costa Rican while here? _______ 3. How many tourists or foreign students do you know of who have had sexual relations with a Costa Rican while here in Costa Rica ? ______ 4. How many tourists or foreign students do you know of who have had sexual relations with a Costa Rican while here in Monteverde ? 5. Based on what you have seen, how common do you think the use of alcohol is in Monteverde? ___ Very common ____ Common ____ Not too common ____ Rare ___Dont know 6. Based on what you have seen, how comm on do you think the use of drugs is in Monteverde (in in cluding alcohol)? ___ Very common ____ Common ____ Not too common ____ Rare ____Dont Know 7. How readily available do you feel condoms are in Monteverde? __ Very available __ Available __ Somewhat available __ Hard to find __ Impossible to find __No idea or Not applicable 7. How much have you seen in terms of HI V educational materials such as posters or flyers in places such as discos and bars? ____ A lot _____ Some ______ A little ______ None _______Dont know If you have seen them, where was that? _______ 8. What do you think would be the best wa y to reach tourists with HIV prevention messages? __________________________________________________________________ 9. Please add any other comments you consider appropriate Thank you for participating

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145 Appendix E Sample of Questions from High School Discussions If two people do not have sex, are they still able to catch AIDS? Who is more likely to be infected, men or women? Is there a cure for HIV? Why isnt there a cure? Are there other fatal STDs? What is gonorrhea? Is it worse than syphilis? What are the other types of STDs? What is the probability of being infected with HIV? What methods of protection are 100% effective? How are you able to tell if someone you ha d sex with is infected with HIV? What methods prevent HIV and what is the correct way of using them? If you use a condom, are you stil l able to catch a STD? Can someone infect someone else by kissing them? Can you catch HIV from having oral sex?


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