Methadone

Heterosexual women of color are among the groups that are at increased risk for HIV infection in the United States (Amaro, 1995; Centers for Disease Control and Prevention, 2003a, 2003b; Goldstein & Manlowe, 1997; Karon, Fleming, Steketee, & De Cock, 2001; Kippax, Crawford, & Waldby, 1994; Zierler & Krieger, 1997). Women overall constitute an emergent part of the HIV/AIDS epidemic. In 1992, women in the United States represented about 14% of adults and adolescents living with AIDS; by the end of 2003, this percentage had increased to 22%. Moreover, African American and Latina women together make up about 25% of all U.S. women, yet they account for 83% of AIDS diagnoses reported in 2003 alone (Centers for Disease Control and Prevention, 2003a, 2003b, p. 1). Heterosexual contact is by far the primary source of HIV infection among women, and at least one-third of heterosexually-acquired AIDS cases in women are ascribed to unprotected intercourse with an infected male injection drug user (IDU) (Brown & Beschner, 1993; Centers for Disease Control and Prevention, 2003a, 2003b; Guinan & Hardy, 1987).

In addition, rates of intimate partner violence among women in substance abuse treatment programs are two to three times higher than rates found in general population surveys, which indicates gender and power processes at work among drug-using groups that make it even more difficult for women in intimate relationships to negotiate safer sex and other forms of HIV protection (American Medical Association, 1992; Bennett & Larson, 1994; Browne, 1993; Gilbert, El-Bassel, Schilling, Catan, & Wada, 1996; Morrill & Ickovics, 1996; Plichta & Abraham, 1996; Wingood & DiClemente, 1997). It is this picture of emerging HIV risk among ethnic minority women with drug using male partners that calls for more intensive studies of how men and women perform in intimate relationships. As of yet, few researchers have examined these public health concerns from the men's perspective. In the present study we contribute to this knowledge base by exploring the accounts and reasons for engaging in HIV risk-taking behaviors reported by heterosexual men in methadone maintenance treatment programs (MMTPs) who have recent histories of partner abuse.

"Accounts" are story-like interpretations and explanations that order and organize meaning in social life. The concept of accounts was traditionally circumscribed to excuses for and justifications of socially undesirable or deviant behaviors (Scott & Lyman, 1968). More recently, account-making was expanded to include any meaningful "means of weaving together disparate social events" in connection with stressful or striking situations (Orbuch, 1997, p. 457). In this view, both life crises and epiphanies are made sense of via accounting. In fact, it can be argued that social identities and their sense of continuity are generated and maintained by endless creative and indexical accounting (Auer & Di Luzio, 1992; Lucy, 1993). It should be emphasized that accounts and account-making include not only narrative storylines to protect the self but also culturally embedded normative expectations and interpretations. Through the study of ex post facto accounts, collective understandings of prescribed and proscribed ways of acting and thinking can be analytically revealed. In short, accounts provide a link between culture and individual motives. They show how social actors "align" their individual behavior with culturally sanctioned narratives to restore meaningful order in their social interactions. Such circulating cultural narratives are always more or less implicit in the construction of these individual accounts.

In the case of HIV risk-taking, individuals often "account" for sexual or injecting behaviors that can be deadly in connection with HIV infection by aligning those behaviors with broader cultural scripts and "recipes for action" that offer a sense of meaningful direction (Bloor, 1995; McKeganey & Barnard, 1992). These "recipes for action" are constantly updated and drawn from the collective culture within which individuals interact. Most individuals have access to a rich and wide variety of circulating cultural narratives that enable them to construct more or less consistent accounts of their risky behaviors. In fact, diverse articulations and constellations of these cultural narratives may have very different implications for the transmission of HIV.

In this light, phenomenological and dramaturgical approaches to social action have guided the interpretation of our study findings (Bloor, 1985, 1995; Bloor, McKeganey, Finlay, & Barnard, 1992; Dingwall, 1976; Garfinkel, 1967; Goffman, 1955; McKeganey & Barnard, 1992; Schutz, 1970). According to these theoretical perspectives, social actors in everyday life work hard at successfully maintaining a sense of interactional continuity with each other. They perform toward each other by feeling accountable to significant absent audiences and by switching between the front and back stages of their selves in light of subtle but shifting framings or relevances of the interaction itself. To get the task done and guide their behavior, they use or compare their improvised situations to rich constellations of the different cultural narratives in circulation (i.e., a variety of stocks of knowledge, of expectations and scripts, of recipes for action, of appropriate presentations of self). These interactional performances can be more or less discursive or routinized depending on the participating actors' mutual assumptions of their familiarity with the situation. Many cultural narratives, especially complex narratives about the self, are experienced as everyday life routines, unless interactional junctures make them discursively explicit. Phenomenological and dramaturgical approaches offer powerful analytical tools to understand how account-making and circulating narratives articulate with each other in daily life. They shed light on why subtle (or not so subtle) interactional switches between HIV safe and unsafe behaviors occur in risky situations, and on how circulating narratives help make sense of such risky switches.

Other explanations of HIV risk behavior using cultural expectations have been proposed in the literature. However, these culturalist models, in contrast to dramaturgical and phenomenological ones, do not bring enough complexity and malleability onto the act of risk-taking. Some of these models theorize "folk" perceptions of risk as a characteristic of local cultural variation. For example, in anthropologist Mary Douglas' (1985, 1992) view, some cultures are more risk-prone (or, conversely, risk-averse) than others according to various degrees of cultural conformity and social integration. However, Douglas' own application of her model to HIV risk has been criticized for being too rigid and static in the allocation of risk cosmologies, in particular her reification of "drug addicts" in what she defines as isolated "fatalists" (Bellaby, 1990; Bloor, 1995; Douglas & Calvez, 1990; Johnson, 1987). These culturalist models seem to neglect a much wider diversity of circulating cultural narratives that are involved in the making of HIV risk-related cosmologies. Thus, for example, fatalistic narratives of inevitable HIV infection among "drug addicts" do not act in a vacuum but in complex articulation with other everyday cultural narratives on normative ways of presenting the gendered or masculine self. Moreover, rigid culturalist models overlook the contextualized switches among different, sometimes contradictory, cultural narratives that individuals activate (or deactivate) during HIV risk-taking episodes according to various relevant situations or even life-course stages. In many instances, for example, overarching so-called "risk-prone" cosmologies carried by social actors into a risky situation may be less influential for HIV transmission than sudden phenomenological negotiations and power asymmetries of the (micro)situation itself. Thus, cultures or subcultures should not be construed as either monolithically risk-prone or averse. In any particular HIV risky episode, individuals draw on a variety of cultural narratives to make sense of their risky behaviors; some of these circulating narratives are local, but others are more widespread and global.

The purpose of this article is to distill and map out the different overlapping accounts reported by heterosexual men in MMTPs that make sense of their HIV risk behaviors. Through the analysis of these accounts, the cultural narratives that circulate among these men and that inform their account-making were unveiled. Using rich qualitative data generated by 10 focus groups, we explored the various types of rationalizations and justifications that these opiatedependent men tell and retell themselves and others in connection with their HIV risk-taking behaviors. The HIV-risk account-making typology presented in this article offers a subset of all possible cultural narratives from which these men draw their meaningful building blocks to construct their risky accounts. In this sense, the qualitative unveiling of the cultural narratives used by these men to justify their risky behaviors has important implications for HIV/AIDS prevention and intervention. Knowledge of the diversity of such accounts and narratives can help to improve the design of more specific programs targeted at this particular risky population.

METHOD

Recruitment, Screening Measurement, and Eligibility

Study participants were recruited from four methadone clinics in Harlem, New York City, from May 1999 to July 1999. Recruiters handed out flyers about the study to potential male participants in the waiting rooms of the methadone clinics. Participants were also referred to the study by the clinic staff. A total of 408 men were recruited and agreed to participate in a 15 min screening interview.

The screening interview covered demographics, drug use, sexual behavior, HIV risks, length and type of intimate relationships in the past year, and the physical aggression and sexual coercion subscales of the Revised Conflicts Tactics Scale (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996). The physical aggression and sexual coercion subscales measure the extent to which intimate partners have engaged in minor and severe physical or sexual attacks on one another during the past 12 months. The purpose of this brief interview was to determine eligibility for participation in focus groups and in-depth interviews to explore contextual meanings and mechanisms that link partner violence and HIV.

To be eligible for a focus group, a participant must have: (1) been over 18 years old; (2) been enrolled for at least 3 months as a patient in a MMTP; (3) during the previous year, had an ongoing sexual or romantic relationship that lasted for at least 3 months with a woman whom he considered his girlfriend, wife, common-law wife, or female lover; and (4) during the previous year, perpetrated a violent act, as measured by the physical aggression or sexual coercion subscales of the Revised Conflict Tactics Scale, on any of his female partners. A maximum of three intimate partners per participant was elicited. Of the 408 men recruited, 101 (24.8%) were eligible for the study. Of those eligible, 62 men (61.4%) participated in 10 focus groups from May to July 1999, averaging 6 participants per group (range: 4-10). Participants received compensation of $25 for participating in the focus group.

Sample Characteristics

The mean age of the focus group participants was 40.9 years (SD = 6.6), and their mean education level was 11.4 years (SD = 1.5). The majority were Latino (48.4%, n = 30) and African American (37.1%, n = 23). Of the total sample, almost three-quarters (72.6%, n = 45) were currently unemployed, one-quarter (25.8%, n = 16) had been homeless in the past year, almost one-half (45.2%, n = 28) had not had money to buy food at some time in the past year, and over two-thirds (71.0%, n = 44) had received some type of public assistance in the past year. Over one-fourth (29.0%, n = 18) had spent some time in prison in the past year.

Of those who had drunk alcohol in the past 6 months (61.3%, n = 38), almost two-thirds (63.2%, n = 24) had become intoxicated. One-half of the sample (51.6%, n = 32) reported having used heroin in the past 6 months. Two-fifths (41.9%, n = 26) had used cocaine, and one-fifth (21.0%, n = 13) had used crack in the past 6 months. Finally, over one-fourth (27.4%, n = 17) had injected some type of drug in the past 6 months.

One-fifth (21.0%, n = 13) had had more than one intimate partner in the past year. The vast majority (95.2%, n = 59) reported having perpetrated some type of minor physical abuse to at least one partner, and almost one-half (45.2%, n = 28) reported having perpetrated severe abuse. Two participants (3.2%) reported having used force or the threat of force to make a female partner have some kind of sex interaction.

Focus Group Methodology and Protocol

We conducted 10 focus groups, each of which lasted approximately 2 hr. During the first 15 min, we reviewed the consent form, including discussion of the purpose of the study, confidentiality procedures, and participants' rights. The institutional review boards of the participating MMTPs approved the protocol for this study. All focus groups were audiotaped.

Three male researchers were present during the focus group sessions. One facilitated the focus group, a second was in charge of reading consent forms and logistics, and a third took notes and read a short summary of the discussion at the end of the session. The first author facilitated 7 of the 10 focus groups. At the completion of each focus group session, both the facilitator and the notetaker completed post hoc questionnaires that assessed group rapport and overall communication (e.g., who were the major communicators, whether various speech styles were used: clear, dispersed, respectful, rich), group dynamics (e.g., whether participants knew each other previously, whether they were engaged or disinterested), and content coherence (e.g., whether there was overall consensus or significant disagreements).

Following methodological guidelines set forth by Morgan and Krueger (1997), we organized the focus groups around introductory, transitional, key, ending, and evaluative questions. The facilitator opened the focus group by introducing the general topic of discussion to foster conversation among participants and then transitioned the group to key questions. The core of the discussion consisted of 8-10 key topical questions and probes. The last 10 min were devoted to asking the participants for the points they thought most important, whether we had missed anything from a short summary given by the notetaker, and their advice to improve future groups.

We prioritized topic specificity over saturation by designing three different types of focus groups, each of which explored one of three analytical areas of interest: Type A, B, and C. Four Type A focus groups explored the relationship between sex-related HIV risks and violence in intimate relationships; three Type B focus groups explored HIV risks and sexual violence; and three Type C focus groups explored HIV risks and drug violence. The design of these analytical areas of interest was guided by feminist and ecological theories and by our own previous research.

Type A groups focused on conflicts over condoms that may arise in intimate relationships, hypothetical reactions to a request for a condom by an intimate partner, when it feels right to stop using condoms in an intimate relationship, STD and/or HIV disclosure in the intimate relationship, and solutions to avoid physical conflicts over condoms and STDs in the couple. Type B groups focused on men's and women's different sexual drives and potential conflicts, hypothetical reactions to a refusal for sex by a female intimate partner, when a "no" is really a "no," issues of sexual performance and substance abuse, and monogamy's "double standard" for men and women. Type C groups focused on potential conflicts over drug splitting, sharing, and procurement in the intimate relationship, attitudes toward sharing needles in the couple, hypothetical reactions over refusal by female intimate partner to share needles, and solutions to avoid physical conflicts over drugs in the couple. Across the three types of focus groups, study participants expressed many overlapping and intersecting accounts and rationalizations for engaging in HIV risks. Because no obvious relationship between type of account and type of focus group was found, all qualitative quantifiers (e.g., most, many, some, few) used in this study to report proportions of participants are based on all 10 focus groups as a whole.

Data Analysis

Focus group data were analyzed by the authors using a modified version of grounded theory (Emerson, Fretz, & Shaw, 1995; Glaser & Strauss, 1967) and following methodological guidelines set forth by Morgan and Krueger (1997). First, audiotapes of focus group sessions were transcribed verbatim. These transcripts were all subject to revision and quality assurance checks. Second, transcripts and post-hoc process assessments were read carefully to get a rough sense of the "big picture" and to recognize dynamics, preliminary patterns, and conceptual comparisons. Third, analytical coding of the transcripts began at two levels: open-coding or line-by-line analytical reading of the transcript to identify and formulate unexpected ideas, themes, and/or issues close to the "raw" data; and focused-coding in which priority was given not only to research questions and analytical interests but also to bottom-up themes and issues that stemmed from the open-coding. A "thematic tree" with growing branches that followed core themes and subthemes was progressively created. Selective coding was used by first coding Type A focus groups, then Type B, and then Type C, and by building up successively as we moved along from one group type to the next. Continuous communication flow among the three authors in frequent working meetings ensured conceptual standardization of the thematic tree and other reliability issues. Differences regarding thematic areas and domains were resolved by consensus of all three authors. Fourth, at any stage of the analytical process, memos that captured ideas and insights were written to clarify and integrate the various thematic findings. Fifth, in a final effort at synthesis, major thematic branches and subbranches were linked in various explanatory stories or arguments. Focus group passages and quotations were selected for this article because they were either representative (i.e., opinions held by a majority of participants) or illustrative (i.e., relevant examples) of important thematic findings. Qualitative analysis software package QSR-NUD* IST4 was used to aid in the processing and classification of all analytical coding and to facilitate conceptual comparisons within the thematic tree.

Limitations of the Method

The focus group findings presented here are meant to be suggestive. Convenience sampling procedures and small sample size render these qualitative data not widely generalizable. The typology of HIV risk-taking accounts presented here is preanalytical and based primarily on face-value similarities (analogy) rather than origins (homology). Because the study sample was self-selected, we do not claim that the typology presented here is exhaustive of all possible risky accounts that exist among men in MMTPs. Moreover, we do not claim propositional truth or falsity of what "really" went on in the various behavioral and accounting claims, but simply "post-hoc" rationalizations of action from the point of view of the life-world of the focus group participants. Thus, for example, the "true" motivational reason why an individual scapegoats a condom for his failed erection in the context of casual sex is unattainable with focus group methodology. However, the fact that the individual perceives, and many others in the group agree, the condom as the cause of his failure to perform sexually, that is to live up to his masculine self-image, is highly consequential for HIV/AIDS intervention research and prevention. Finally, we did not separate men into distinct focus groups based on ethnicity or race. In this connection, we cannot explore in this article how race relates or interacts with account-making and reasons for engaging in HIV risk behaviors.

RESULTS

Four analytical types of HIV risk-taking accounts emerged from qualitative analysis of the focus groups of the study sample (see Table I): (1) Nihilistic accounts; (2) Hedonistic accounts; (3) Fatalistic accounts; and (4) Normative accounts. We emphasize that these accounts are ideal types and rarely found in isolation in the real world. In fact, constellations of multiple and sequential accounts and corresponding cultural narratives that work in tandem are the empirical norm in everyday life, such as, for example, combinations of hedonistic and normative types, or combinations of nihilistic and fatalistic types, etc.

Nihilistic Accounts

We characterize nihilistic accounts as personal stories that make sense of HIV risk-taking behavior by drawing on collectively sanctioned narratives of drug-dependent lifestyles. These cultural narratives define drug-dependent lifestyles as desperate, senseless, and self-destructive. In the episodes that are the object of nihilistic accounts, HIV risks may be accurately estimated or even alarmingly overestimated (false pessimism) by individuals. However, for all practical purposes such heuristics become irrelevant in guiding a man's behavior because: (1) feelings of drug dysphoria, cravings, and/or sheer pain typically reach an emotional "point of no return" where preference for own and other's future well-being is heavily discounted; and/or (2) future quality of life may be perceived as having negligible marginal utility among hard-core drug users. In other words, when all material and symbolic resources to invest in future well-being are gone and depleted, one more tomorrow is simply more of the same "hell."

It should be noted that even in these nihilistic episodes where agents seem to discount the future completely, their "reward" function (i.e., demand for drugs) is never completely price-inelastic. (4) Thus, drug-dependent individuals can and do moderate the intensity of their drug cravings according to various available cognitive beliefs or other imminent risk factors in their surroundings, such as the fear of a police raid in the neighborhood, which may prevent them from going out to buy drugs, or the suspicious quality of a drug just purchased from an unknown dealer, which must be tested in patient and slow doses, etc. In fact, there is a wealth of literature on the "price elasticity" of alcohol, nicotine, and other drug addictions (Edwards, 1994; Elster, 1999; Orford, 1985). However, it became clear from the cultural narratives that circulated among the focus group participants that drug cravings, especially those due to heroin withdrawal, were considered to be essentially price-inelastic. In short, most accounts of nihilistic HIV risk-taking among participants draw and legitimize themselves on such price-inelastic drug narratives.

We found two subtypes of nihilistic accounts in the qualitative analysis of our focus groups interviews (see Table I): (1) drug dysphoria, and (2) life's diminished marginal utility.

Drug Dysphoria: Dope Sick

In this connection, at least two types of drug dysphoria have been experienced by the study sample: (1) heroin withdrawal, and (2) cocaine craving. A general theme that appeared frequently was that avoiding heroin withdrawal or the "desperation of getting straight" makes a person engage in serious HIV risky acts, such as sharing dirty needles. In this line, many participants across all focus groups talked about their risky experiences during heroin withdrawal or when "dope sick." Some of the most extreme ones are worth mentioning here, such as using dirty water by the railroad tracks to rinse and prepare the heroin "fix," using rainwater from dirty puddles for the injection solution, or using disposed syringes from the street that have blood inside them. One participant summarized these generalized views as follows: "When I'm dope sick, I want to get off. You tell me you got AIDS, I don't give a fuck, I'm dying now. I'm dope sick." Another insisted that, when he is seriously dope sick, "if that was the only set of [dirty syringe and cooker] works that was there, I take a shot and use it."

Cocaine Hyped Up

Regarding cocaine cravings and HIV risks, one focus group participant clearly summarized what other cocaine users had expressed as well that "when people shoot cocaine, once they're hyped up they don't care about a clean set of works. They don't care about nothing. They're paranoid. They want to get the next shot ... and there is no needle cleaning."

Life's Diminished Marginal Utility: The Death Wish of Addicts

Another set of self-destructive nihilistic accounts of HIV risk-taking reported by these men in MMTPs related to their overall life's diminished marginal utility, or in participants' ("emic") terms "the death wish of addicts." One participant in nihilistic desperation expressed that "sometimes in the back of my mind, I kept shooting drugs to perhaps get that AIDS. I wanted to die ... I thought it was a blessing. AIDS kills. There's a lot of people ... you know, that are fucked up, and I'm one of them." Another said: "I'm always going to be a junkie no matter what, and the type of attitude we have ... is that we don't care. It's like a death wish to us." For many participants across all 10 focus groups, addicts "have a sense of a suicidal tendency," are "tired of living," or have a "don't give a fuck" kind of attitude. In general, they "don't care about themselves. They don't care about getting sick. They don't care about HIV." At least one participant implied that drug lifestyles do not cause nihilism, rather it is the other way around: "All addicts have a suicidal tendency. That's why we're addicts, you see."

The World Owes Me Something

An interesting variation of these nihilistic themes of self-destruction was related to a shift in the intentional object of the destructive behavior, from self to others. Thus, according to quite a number of participants, besides being self-destructive many people infect others with HIV out of rage or revenge. One participant told the story of an HIV seropositive woman he personally knew who willingly spread AIDS; she was "angry and she wanted to take it out on another person ... she's like 'fuck it, you're going to have it."' Another participant knew a woman who was infecting everybody because "she was getting back at men because she got abused by men so much ..." One participant concluded that some people that contract HIV "become miserable ... they feel as though the world owes them something, so they go out intentionally to spread it." It is interesting that "The world owes me something" was an account typically reported in reference to desperate women.

Hedonistic Accounts

We characterize hedonistic accounts as personal stories that make sense of HIV risk-taking behavior by drawing on collectively sanctioned narratives of pleasure and euphoria. These cultural narratives define pleasure and euphoria as blind and impervious to consequences. During the episodes that can elicit hedonistic accounts two things can happen: (1) an individual's future safety becomes irrelevant, or (2) HIV risks are hopelessly underestimated (false optimism). Two possible motivational mechanisms may be at play: (1) in this case, intense feelings of drug euphoria and/or sexual arousal may reach an emotional "point of no return" in which preference for own and other's future well-being is heavily discounted; and/or (2) "wishful thinking" processes where drives shape beliefs, such as when intense sexual desire distorts HIV risk perception to suit an individual's comfort level of safety. For example, an individual may become so aroused by a sexy one-night-stand that he wishfully thinks it is fairly safe to perform unprotected sex if only just once. However, in his probabilistic assessment, this individual has conveniently overlooked the fact that he has had quite a number of "only-just-once" unsafe partners in his recent past. In short, most accounts on hedonistic HIV risk-taking among participants draw and legitimize themselves on such narratives of blind euphoria and arousal.

We found two subtypes of hedonistic accounts in the qualitative analysis of the focus groups (see Table I): (1) sexual arousal, and (2) drug/alcohol euphoria.

Sexual Arousal: In the Heat of the Moment

Most participants across all focus groups expressed the idea that "people know the risk is there but sometimes in the heat of the night ... shit happens." Similarly, "in the heat of the moment, your foreplay is already gone and the condom goes to hell." The expressions "in the heat of the moment" or "in the heat of the night" were used again and again by focus group participants in connection with taking HIV risks. When they were asked to define it, a focus group participant responded: "The passion is stronger than the passion of being safe." Another participant was also very illustrative: "[HIV] education is good ... but most of the guys, for example me, when I get horny ... I'll stick anybody besides men." Other powerful rhetorical expressions in connection with arousal and unprotected sex were: "Once legs go up, your whole mind goes blank," "[men] are thinking with their 'dick' head instead of their 'big' head," or sex without condoms is like "playing the Russian roulette."

Not to Miss That Opportunity

A related theme that came up several times in many focus group discussions was the notion that beautiful and sexy women are hard to come by. Therefore, once a man gets a beautiful woman in bed it becomes too costly to miss that opportunity just because condoms are not around. Thus, one participant in connection with HIV risk-taking and beautiful women said: "Because she look good ... [you] take a chance not to miss that opportunity." Similarly, another expressed: "I would say [men] have a few beers, you know if they drink a little bit and they ain't got a condom, [and] that's the only chance they're going to get ... to get that pussy ... if I can't get it tonight, there might not be another chance down the road."

Drug/alcohol Euphoria: Not in the Right State of Mind

Most participants agreed that a drug high impairs thinking when it comes to HIV risks. Thus, a widespread theme across all focus groups was that people take HIV risks because they are not "in their right state of mind ... [they] may be high or fucked up." Or that one should "get rid of any bad thinking that gets you into that [sexual] situation because when you use drugs and alcohol your thinking ... you ain't there. Nobody can tell me that they can do their best thinking when they're under the influence ..." Similarly, safer sex when high is "more difficult for me because you're impaired. You don't know half the shit going on." One participant indicated that under the influence of drugs you never know when to stop pushing your partner for sex. Thus, when sober "you might have found out [that she doesn't want sex] in the fifth try ... but being high is going to take 10 for you to get it clear."

Drugs Made Me so Horny

In addition to cue misreading and other cognitive impairments, drug and alcohol euphoria may lead to HIV risk-taking because it is perceived to enhance sexual drive, thus increasing rates of discounting future consequences of behavior and decreasing "point-of-no-return" emotional thresholds. In one risky story, a participant high on cocaine and knowing for a fact that his sex partner was HIV seropositive engaged in unsafe sex: "I went with the girl [to a hotel], we were hanging out. We had money, you know, and then ... you know, I even went to the lobby to get a condom and said 'fuck it, man,' you know, 'cause when you're getting high ..." In short, this participant traded his future well-being for an imminent night of passion. Another participant explained that drugs made him so sexually aroused that he forced his sex partner to have risky sex: "drugs is what made me so horny and shit ... I mean if it wasn't for the drugs maybe I would have stopped, but the drug was pushing me more and shit." In another story of drugs and unprotected sex, "I did something that was silly. I fucked a woman ... with no rubber ... I was high ... you do stupid things. I wouldn't have done that if I was sober."

Hedonistic accounts are used by these men on methadone to make sense of their HIV risk-taking behaviors within the context of broader narratives of "irrational" pleasure and euphoria. It should be emphasized, however, that behavioral and neurological researchers have not found that euphoria and arousal is "reward insensitive" or completely blind to behavioral consequences (Elster, 1999; Orford, 1985). Thus, individuals interrupt passionate moments or drug "highs" all the time if something more relevant or dangerous comes up, from a sports game on television to an imminent life threat. In many instances, culturally-sanctioned beliefs about the effects of alcohol and other drugs exempt individuals from moral or agentic responsibility during addictive binges. A kind of cultural "time out" where "irrational" behavior is more or less tolerated and even forgiven, as, for example, exonerating a drunk husband when he beats his wife. Similarly, individuals may feel less social pressure to keep up their HIV/AIDS protective strategies during their addictive binges. In this connection, narratives that sanction drugs and sex as "irrational" and impervious to HIV consequences may not so much reflect blind pharmacological or neurophysiological processes at work but cultural "time outs" where any undesirable behavior can be legitimized later by blaming the drugs or sexual excitement (Kantor & Straus, 1987; Parker & Auerhahn, 1998).

Fatalistic Accounts

We characterize fatalistic accounts as personal stories that make sense of HIV risk-taking behavior by drawing on collectively sanctioned narratives of inevitable fate or sacrificial love as destiny. These cultural narratives define whether one becomes HIV infected as part of a foreordained plan that is beyond individual agency. In the episodes that are the object of fatalistic accounts, HIV risks are not a matter of concern, and can be either underestimated (false optimism) or overestimated (false pessimism). In any event, such heuristics become irrelevant in guiding safer behaviors because HIV infection is ranked as subordinate to transcendental values outside the agent's control. It can be argued that in fatalistic accounts the agent has adopted "thin" rather than "broad" forms of rationality. (5) Thus, the individual can be said to be rational (albeit "thinly" rational) in that he properly aligns his actions (unsafe sex) in agreement with his reasons (beliefs and wants) for acting, namely, (1) his transcendental belief in invulnerable fate or sacrificial love, and (2) his desire to be subsumed within those transcendental truths or values. The agent in this case, however, does not act "broadly" rational because his beliefs themselves are clearly motivated and not transparently rational. In other words, his beliefs do not build on independent judgment of available evidence but are shaped by his strong desire to belong to something "greater" than himself, such as the values of love or fate. For example, in the simplest scenario, an individual may believe that he is invulnerable to HIV infection because he feels chosen by God. He is rational in the "thin" sense because he ignores HIV risks in accordance with his belief that he is invulnerable to disease. To be "broadly" rational, however, he would have to revise his belief of invulnerability systematically, and conclude that no amount of faith in fate or God can refute the available epidemiological evidence that continuous exposure to HIV is highly correlated with HIV seroconversion and, eventually, with AIDS.

We found two subtypes of fatalistic accounts in the qualitative analysis of the focus group interviews (see Table I): (1) love as sacrificial destiny, and (2) invulnerable fate to disease.

Love as Sacrificial Destiny: Till Death Do Us Part

A handful of participants across all focus groups mentioned that AIDS is irrelevant if there is true love. Thus, "I say to myself I really love that girl, right?... you know, whatever her problem is, it's my problem too ... they say it's until death do us part ... if it happens to her, let it happen to me." One participant clearly maintained that the only way he envisioned getting infected "would be out of love." Another was convinced that, even if he became infected with HIV, "I know my woman would stay with me."

One participant elaborated on these sacrificial themes regarding sharing needles with his wife: "That's [my wife] who I'm going to be with the rest of my life,... we know we're going to be [together],... if I'm going to get it [HIV], she's going to get it, you know what I mean?" Another participant continued to share needles with his wife even after he found out she was HIV seropositive "because she's my wife ... [and] we've been together all the time." This same participant took an HIV test just to let his wife know that he was seronegative but that he would keep sharing needles with her regardless, "you know, I did it afterwards [take the test] to show my love."

Invulnerable Fate to Disease: I Ain't Gonna Get It

A number of focus group participants claimed that some "people think that they can't get [HIV] ... people think like they're invisible or something." Others added that some people think they are "immune" to HIV. In this connection, one participant reasoned that because he had been with his HIV seropositive wife practicing unprotected sex for years and never got infected, "I'm still going to make out [unsafely] or whatever. In my mind I know that I'm not going to get it because I didn't get it throughout the time that I was with her." In another instance of inevitable fate, another participant stated that: "either you had it then or you ain't going to get it at all, period. That's all."

Fatalistic accounts were clearly not as widespread as the other account types, such as nihilistic, hedonistic, or normative (see below). In this connection, only one participant felt invulnerable to HIV because of his strong "faith of God." It is surprising that he was the only one in this focus group sample to use a religiously-oriented fatalistic account.

Normative Accounts

We characterized normative accounts as personal stories that make sense of HIV risk-taking behavior by drawing on collectively sanctioned narratives of the appropriate presentation of the social self. These cultural narratives offer prescribed and proscribed scripts and rituals of presenting and saving the self's face according to particular interactional events. (6) In the episodes that are the object of normative accounts, HIV risks are either (1) typically underestimated (false optimism) or (2) due to face-loss, the emotions of shame and/or anger can distort the future so that it becomes irrelevant. Two possible motivational mechanisms may be at play: (1) "wishful thinking" processes where motives shape beliefs, namely, the normative pressures to save face in an interaction may lead the social actor to underestimate HIV risks in order to avoid breaching a scripted or ritualized "working consensus," (7) a consensus about what it means to behave in socially appropriate ways, and/or (2) if indeed there is irreparable face-loss after breaching a working consensus, the emotions of anxiety, shame, or even anger may reach a "point of no return" where preference for own or other's future well-being is heavily discounted.

We identified at least three subtypes of normative accounts (see Table I): (1) presentations of the masculine self, (2) presentations of the healthy self, and (3) presentations of the faithful self.

Presentations of the Masculine Self: My Way or the Highway

Most participants across all focus groups concurred that men "set the tone" in their sexual encounters. They said that men are about being "in control" of the situation. As a consequence, many men are "hurt when denied sex" by their female partners. One participant clearly expressed that to be denied sex is a "toss up 'cause you don't know what might be on a man's mind when you be denied any sex." Another participant mentioned how immature men can be when they are denied sex: "We, as men, we think we're strong and that, but sometimes we get our feelings hurt and instead of knowing how to deal with it in a mature way, we're like little kids ... running out and going to get another broad to satisfy you is like a little kid throwing a tantrum." In connection with his main partner requesting protected sex, one risky participant admitted that it used to be "my way, you know, or the highway. You know what I'm saying? And not thinking about my loved ones ..."

Women Like Raw Sex

Another set of themes was related to the notion that many men found pride in giving a woman pleasure. Thus, several participants across the focus groups expressed that they loved to satisfy a woman sexually, for example: "I love to take my time and do everything she asks me to ..." or "I focus more on satisfying her than myself ..." One participant took pride in giving his partner multiple orgasms in every sexual episode: "I'm a freak at that, I want to see how ... in what little time I can make a girl come as fast ... I don't know why it drives me crazy."

It is interesting that quite a number of focus group participants believed that most women only reached orgasm if they felt a man's ejaculation inside, and that was why some women "have one male use a condom but they have another male don't use condoms so they [women] get their climax." As a consequence, unprotected sex allows for orgasm synchronization between a man and a woman because, according to the above view, it is only when a man ejaculates inside a woman that she can reach her orgasm. Put another way, "that helps [her] climax too ... because if I climax ... you know she's coming ... that wetness, because as you are making love, she is getting very wet inside ... [and] you're getting more excited." This "risky" belief (i.e., that women only climax without condoms in direct contact with a man's ejaculation) has significant consequences for the spread of HIV/AIDS, especially if one of the components of the "masculine identity" equation involves satisfying a woman sexually. One participant summarized it this way: "Females want to feel raw dick inside them ... they tell you that [raw dick] is part of the sex act ... to feel the male."

Condoms Don't Make You a Full Man

Although some participants had a favorable attitude toward condoms, the overwhelming majority across all of the 10 focus groups viscerally disliked condoms. One participant captured nicely this widespread consensus by saying that a condom "doesn't make you a full man. I guess your ego, you know ... it does nothing for your performance." Two reasons emerged as to why men dislike condoms: First, as with women, many participants thought that condoms impaired sexual excitement by preventing direct skin and fluid contact, "I don't want to put no rubber on, I want to go ahead and get your skin ... I like to feel that wet pussy ..."; and second, for other participants, condoms impaired full erections because they became a distraction during sex.

In this connection, condoms were often perceived by participants to be related to their failure to perform sexually by getting in the way of their full erections. In other words, condoms let you down as a full man. One participant expressed his concerns by saying that "anything that interrupts when I'm getting ready to make love, anything that interrupts that process. I'll lose my [erection] ... you know, my dick goes down like crazy, man." Also, condoms always "seem kind of clumsy and like when you're at the moment when you're with somebody you want to have sex, you just want to get it on ... dive right in." Another participant elaborated on the hassle of putting on a condom during foreplay: "... because it takes time to put it on ... like when you're doing foreplay, you might not stay erect the whole time. So you can't put it on before. And after you finish foreplay, right, and you want to get into the [vagina] ... you got to stop and unroll this thing on your joint, and it takes something away ..." Other rhetorical phrases in connection with putting on condoms and erection problems were: "I may be hard, by the time I open that condom, I'm soft again," "It's the freaking rubber thing that's doing it," "it spoils the moment," "your dick might go limp," "you might not get none."

Many of the focus group participants expressed how stressful it was to lose an erection during sex. This was not so much because "once you lose it [the erection], it's hard to get it up again ... [and] no matter how hard you try, that shit won't get hard," but because a woman may imagine that her nonerected man is having an affair with another woman or even that he is gay. Thus, for example, one participant's sex partner reproached him that "you couldn't get hard, because you're with the other girl." Another participant recalled several times getting high on crack and losing his erection, and his woman "though maybe I was gay or something ... 'You're gay!' [she shouted]." (8)

In short, to maintain phenomenological consensus about what it means to be a "man," arduous facework must be deployed to live up to the cultural narratives of being in control of the sexual act, of truly satisfying a woman, and of keeping a full erection. In this light, it is not impossible to understand why for many men such demanding face-work can easily compromise their use of condoms and other forms of HIV-protective concerns. In addition, the lack of normative pressures from significant others experienced by these men on methadone regarding condom use did not help either. Most participants across all focus groups acknowledged that they never talked about condoms and HIV protection with their friends or "homeboys." If anything, they only talked about condoms with their counselors or doctors. In fact, quite a few perceived their friends to engage in riskier HIV behaviors than they themselves did. In this connection, several participants said: "A lot of my friends say fuck that, I don't like using condoms," or "they [my friends] are still wild." It is interesting that one participant claimed that even when his friends said they used condoms, "I might not believe them." Moreover, other participants experienced direct normative pressures by relatives against using condoms. For example, one participant explained how "coming from a Hispanic family, I had a macho image and I thought men that wore protection were less than a man. I thought they didn't know how to do sex and they needed help. My whole perception was wrong." Ask about where he got that perception, he said "I got it from my uncles and my dad ... they used to goof around [making fun of men who used condoms]."

Presentations of the Healthy Self: I Ain't Nasty, Don't Got No Disease

For many men of the study sample and their female partners condoms were markers of sexually transmitted diseases, including HIV/AIDS. In turn, sexually transmitted diseases signaled promiscuity and "moral" pollution, especially in the case of women. (9) In this connection, one participant reported an incident with a casual sex partner in which he suggested that they use condoms, and she yelled at him: "I ain't nasty, don't got no disease." Unfortunately, this breach of assumed healthy selves in sexual interaction was only repaired by dropping condoms altogether and overlooking HIV risks.

Men Are Ashamed to Buy Condoms

The phenomenology of healthy selves in connection with condom use intersected with private versus public face-saving concerns among these men in MMTPs. Thus, a few participants across the focus groups concurred that it was embarrassing to pick up condoms in public from outreach workers on the street because people could assume they were sick: "after she [outreach worker] gives me some condoms, she's probably going to think I'm sick ..." A few participants expressed the idea that some "men are ashamed to buy condoms." Also, "some men are 'acomplejados' [Spanish for having an inferiority complex], for them it is kind of embarrassing to go to the store [to buy condoms]." Moreover, for some participants there was an association between condoms and homosexuality that was clearly stigmatizing in public: "it was a big deal to go to the drugstore and buy condoms ... [we thought it was related to] gay things and stuff like that ..." In this light, it can be argued that the phenomenological "working pressures" to present a healthy face in sexual interaction (but also in public) may lead some of these men and their sex partners to engage in HIV risks.

Presentations of the Faithful Self: Condoms Create Mistrust in the Relationship

Most focus group participants who were married or in monogamous relationships concurred that requesting condoms creates serious mistrust in the couple. In other words, for men in committed relationships, condoms were considered to be markers of infidelity. Most participants expressed how shocked they would feel if their monogamous partners were to request a condom during sex. Thus, among various reactions, participants said that they would have to "question her," that "it creates some kind of mistrust [in the relationship] ... she's been going out with somebody or she thinks I've been going out with somebody," that "it's like I'm back in the prostitutes' house or something. It's very impersonal," or that "it would put a monkey wrench in our relationship." Moreover, at least one participant strongly believed that, if condoms were brought up in an intimate relationship, "there is no reason to be in the relationship ... I don't think it's worth it."

To face up to such demanding "monogamy narratives" of conjugal fidelity, many unfaithful men and women end up practicing unsafe sex with their committed partners. The motivational mechanisms behind the monogamous presentation of self are culturally quite complex but essentially involve shaping HIV-risk perception to save a "faithful" face in the relationship. At least two motivational possibilities may be at play: (1) an individual may "conveniently" believe that all his "affairs" outside his committed relationship were HIV safe and therefore convince himself that there is no need to protect his wife or steady girlfriend from HIV; and/or (2) an individual may "wishfully" think, based on very limited evidence, that his committed partner would never cheat on him or her. The "denial" motivations behind the latter rationalization can be several: for many men, believing in a "good" and loyal wife means to be respected as a man in the community; for many women, keeping a "good" husband is a symbol of status, etc. (Sobo, 1993, 1995). In this line, the phenomenological "working pressures" to present a faithful face in their intimate relationships may lead some of these men on methadone to overlook HIV risks.

DISCUSSION

The results of the present study are important because they bring more phenomenological and cultural complexity into the explanation of HIV risk-taking behaviors. Our study participants reported complex constellations of different cultural narratives that were in circulation in their social worlds--narratives on the consequences of drug dysphoria or euphoria, on the blinding effects of sexual arousal, on sacrificial love in the relationship, on feeling invulnerable to disease, and on the appropriate presentations of the self in the course of intimacy. Our findings suggest that to account for sexual and drug-related HIV risks, these heterosexual men in MMTPs tell and retell themselves and others rich nihilistic, hedonistic, fatalistic, and normative stories built on broader cultural narratives that give them a sense of direction after the risky fact, a "why-things-happened" account (see Table I). Nihilistic accounts of HIV risk-taking make sense by drawing on beliefs of self-destructive and senseless drug-dependent lifestyles. Fatalistic accounts surrender HIV infection to larger-than-life forces that are beyond the individual's control and sense of agency, such as sacrificial love or invulnerable fate. Hedonistic accounts make sense of HIV risk in the context of broader narratives of "irrational" pleasure and euphoria; they create "timeout" spaces where everyday logics disappear and give way to "liminal" spaces of euphoria, the erotic, emotional embodiment, and spontaneity (Davis, 1983; Monagham, 2002). Finally, normative accounts anchor themselves in routine and scripted rituals of social interaction between the sexes; they build on the appropriate presentation of the self in gendered, unpolluted, and monogamous interactions.

Normative accounts have important implications for sex-related HIV/AIDS prevention. They reveal complex processes at the root core where the social meets the sexual. For example, for many of these men in MMTPs, safer intercourse threatens scripted presentations of their masculine self: (1) because complying to condom requests by a female partner surrenders some of their control of the sexual act, (2) because condoms act as "dry" barriers to a woman's "wet" pleasures of feeling the "man," and (3) because putting on a condom implies disrupting spontaneity, which can impair erections. In other words, to maintain an appropriate working consensus of what it means to be a "man," arduous face-work must be deployed in many of these men's gendered interactions and performances to live up to cultural narratives of being in control, of satisfying a woman, and of keeping a full erection (Butler, 1990; Connell, 1995; Gilmore, 1995). This is interactive hard work, to say the least, and condoms have no role interrupting it. In the end, the social risks of losing masculine face in front of a female partner, including embarrassment and humiliation, are very much prioritized over long-run HIV risks.

Moreover, the use of condoms in certain casual contexts can be interpreted as sexual exchanges between selves that are unhealthy and promiscuous. In particular, the tricky associations among disease, condoms, and sexual promiscuity are highly stigmatizing for women, and they spill over into symbolic realms of moral pollution, as they signify historically ingrained ideas of loose and reckless female sexualities. In this light, many women in casual sexual encounters avoid requesting condoms for fear of losing a respectable self-image. Finally, we have seen how condoms create mistrust, or "put a monkey wrench in the relationship" as one of the focus group participants put it. In other words, putting on or requesting condoms without prior and elaborate verbal negotiation can easily breach legitimate images of fidelity and trust in a monogamous relationship (El-Bassel et al., 2001; El-Bassel, Gilbert, Rajah, Foleno, & Frye, 2000; Gilbert et al., 2000; Sobo, 1993, 1995). A husband putting on a condom may send the message that he has cheated or that he is suspicious of his wife. In turn, a woman requesting a condom can signify to her fiance that she suspects infidelity.

In short, among these men in MMTPs, the protective act of putting on, or being requested to put on, a condom in the context of heterosexual relationships may disrupt cultural scripts and social performances of what it means to be a man (because condoms can threaten masculinity), what it means to be a proper woman (because condoms can indicate promiscuity), or what it means to be in a committed relationship (because condoms can destabilize trust and monogamy). From a sociological standpoint, it can be argued that (avoiding) risking the institutions of gender (masculinity or femininity) and/or monogamy (marriage) in the sexual context of self-presentations is more motivationally relevant to these men than risking their lives to HIV infection. For the phenomenological self, to avoid risking the institutions of gender or monogamy is felt as the need to save face in the "here and now," a motivational process that should always be understood as semiconscious rather than strictly discursive.

As mentioned before, risky accounts--whether nihilistic, fatalistic, hedonistic, and normative--are rarely found in isolation but in multiple and sequential narrative stories that work in tandem. Thus, for example, being "dope sick" or on a "drug high" never occurs in a vacuum but in contexts where individuals still need to present their selves in gendered and/or faithful ways. In contrast to more rigid culturalist models of HIV risk-taking indicated in the Introduction, we found that in any particular HIV risky episode more than one type of cultural narrative and account may be used to guide and make sense of behaviors. In fact, complex constellations of account-making that draw on a number of different cultural narratives are typical among these men on methadone. Thus, for example, an individual can account in general for an HIV "unsafe" night of passion with his girlfriend in multiple and very different ways: He can tell himself that he was drunk (hedonistic account) and alcohol makes one do wild things (hedonistic narrative); that he was not only drunk but also very tired of living as a junkie (nihilistic account) and when one is a junkie one is self-destructive about things (nihilistic narrative); that with all his past and present recklessness, if he is not already infected (fatalistic account) he will never be (fatalistic narrative); he can also tell himself that he was not too much into sex that night (normative account) and losing his erection further by putting on a condom would have been pretty embarrassing as a man (normative narrative); that it would have been not only embarrassing but also sexually unsatisfying to his girlfriend (normative account) who expects to be satisfied (normative narrative); or that his girlfriend made him so angry when she refused to have a certain kind of sex that he penetrated her anyway (normative account) because men should always be in control of sex (normative narrative).

In this connection, an individual can feel drunk, but tired of living, can believe he is invulnerable, have potency problems, and feel he is losing control of the sexual act all in one same sexual episode and at different junctures. Our focus group analysis indicates that most ex-post facto accounts reflected in these men's narratives and stories were delivered in various and rich "performative" combinations. Further qualitative studies to elicit complex in-depth narratives are needed to explore which risky account-making combinations are more prevalent and relevant than others according to diverse circumstances and sex partners. From the present study's findings, for example, it appeared that fatalistic accounts are less prevalent than others. Moreover, further research may disentangle the effects of class and ethnicity, drug type, and life course on the diversity of nihilistic, fatalistic, hedonistic, and normative account-making of men on methadone.

ACKNOWLEDGMENTS

This research was supported by Grant #DA12335 from the National Institute on Drug Abuse. The authors express their appreciation to John Key and Dr. Dexter Voisin, who assisted in the implementation and facilitation of the focus groups. The authors are also thankful to the staff and patients at the Beth Israel Medical Center, who made this study possible.

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Jorge Fontdevila, (1,3) Nabila El-Bassel, (2) and Louisa Gilbert (2)

(1) Center for AIDS Prevention Studies (CAPS), University of California, San Francisco, California.

(2) Social Intervention Group (SIG), Columbia University School of Social Work, New York.

(3) To whom correspondence should be addressed at Trayectos Study (UCSF/CAPS), 4094 4th Avenue, Suite 202, San Diego, California 92103; e-mail: jfontdevila@sdtrayectos.org.

(4) "The demand of a good is said to be totally inelastic if the same amount is bought regardless of price (on the assumption that the total cost is within the consumer's budget). If a price increase causes less of a good to be bought (under the same assumption), the demand is said to be elastic. Thus a diabetic's demand for insulin might be totally inelastic, whereas normal consumer demand for chocolate is highly elastic" (Elster, 1999, p. 168).

(5) According to Elster (1999, p. 142): "First, for an action to be rational, it has to be the best means of satisfying the desires of the agent, given his beliefs. In itself, this is a very weak requirement. If I want to kill a person and I believe that the best way of doing so is to make a doll representing him and stick a pin through it, then according to this weak definition I act rationally if I make the doll and pierce it with a pin. We would hardly be satisfied with this conclusion, however, not because homicidal desire is irrational (it may be immoral, but that is another matter), but because my belief is transparently ill-founded. Second, therefore, we need to stipulate that the beliefs themselves are rational, in the sense of being grounded in the information available to the agent." In short, the first type of rational action takes beliefs for granted ("thin" form of rationality); the second type of rational action grounds beliefs in the available evidence of the age ("broad" form of rationality). However, we believe that not even the most grounded of beliefs can be transparently rational throughout. There is always a higher-order taken-for-granted horizon that escapes phenomenological definition. In this connection, rather than a strict dichotomy between 'thin" and "broad" forms of rationality, we propose the weaker claim of an epistemological continuum where beliefs may be located according to whether they are more or less testable or falsifiable.

(6) According to Goffman (1955, p. 222, 226), face is defined as "the positive social value a person effectively claims for himself by the line others assume he has taken during a particular contact" and face-work is defined as "the actions taken by a person to make whatever he is doing consistent with face."

(7) A phenomenological "working consensus" is what takes place in social interactions to maintain face and avoid breaching scripted common sense. According to Goffman (1955, p. 226), "it is typically a 'working' acceptance, not a 'real' one, since it tends to be based not on agreement of candidly expressed heart-felt evaluations, but upon a willingness to give temporary lip service to judgments with which the participants do not really agree."

(8) A few more remarks regarding condoms and erections are worth reporting here. On the one hand, for quite a few participants erections were "a mental thing," in that maintaining an erection during sex had to do more with their power of suggestion than anything else. For example, one participant reported that with some women, those whom he perceived as risky or sick, he thought that condoms had to be used no matter what, so "before you even get high [you know] the condom got to be used, there won't be no sex without it. So you prepare yourself mentally for that condom action before that." This participant implied that there are no erection problems with condoms in a clear-cut scenario where a woman looks like she is highly infective. On the other hand, for other participants, maintaining an erection had to do with the level of sexual attraction they felt toward their sex partner, "there are some women ... [that] I got to put on a condom and there goes the erection, but there are other women that I be with and that I like so much that when I have sex with them, right, my shit stays hard. I put on the condom with no problem. In other words, as another participant said: "[erections] depend on the relationship you have [with] the woman and how the woman interests you."

(9) It should be noted that the "Madonna-Whore" Judeo-Christian narrative that distinguishes between "loose" and "proper" women was pervasive among these men on methadone. According to the opinions of most participants, it can be argued that women were subject to two sources of moral pollution: (1) drug pollution; and (2) sex pollution. In a powerful materialization of such narratives, one participant explained that he stopped sexually forcing a "loose" woman when he realized that she was a virgin. Thus, while she was resisting "I was feeling bad. I'm saying but she is a hooker ... [then I felt] I couldn't [penetrate] her. That's when I realized that she was a virgin ... I pulled out and put my pants back up ... I felt really bad afterwards." In another example regarding who gets a larger share of drugs, "if it's your woman, you got a lot of respect for them 'cause that's your woman. If it's a street girl, it's different ... it's just a whore from the street." In general, quite a number of participants took pride in the fact that their wives or steady girlfriends had never been drug users.

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