Today, while preparing lessons, I was reminded of one of my two favourite journal articles of all time, which reminded me of the other one, and thought I’d give a brief review of both of them here. One is an example of the kind of research that is often sneered at for its social sicencey-content, but is very important for public health, and the other is interesting for no other reason than that, well, it’s very interesting. The two articles are Highway cowboys, old hands and Christian Truckers: risk behaviour for human immunodeficiency virus infection among long-haul Truckers in Florida, by Stratford D et al, published in Social Science and Medicine; and Autoerotic fatalities with power hydraulics, by O’Halloran RL, published in the Journal of Forensic Science. Here is my brief review of each. Both reviews are based largely on memory (I don’t yet have full versions), but my memory of both is pretty clear.
Highway Cowboys, Old Hands and Christian Truckers
This article is a classic example of good quality, detailed research into the social determinants of unsafe sex and HIV risk. From memory, it stemmed from research done as part of a project in the late 1990s aimed at identifying HIV risk behaviour on trucking routes in the US. As such it is an interview-based extension of some snowball-sampled research of truckers on a long-haul route starting in Florida, so the article combines some basic tabular information on unsafe behaviour (condomless sex, gay sex, drug use) and some interviews to flesh out the research from the original questionnaires. The authors have gone further, however, using the findings of the study to divide the truckers they meet into three key groups, who will probably be accessed by different health promotion methods, and one of which may be useful for peer education training.
The research identified several types of high risk behaviour amongst long haul truckers, which are generally understood to exist but which aren’t easily quantified and which they explored in detail through interviews. Before we examine these three types of risk, it’s worth bearing in mind that truckers are actually a pretty hard-to-reach group, and although we have anecdotal reasons to believe they are high-risk for certain diseases (injury, HIV, sexually transmitted infections), getting details on this risk can be hard. The three risk types are:
- Unsafe heterosexual sex: truckers use prostitutes, and the particular type of sex worker who serve the long-haul trucker market are cheap, transient and extremely vulnerable. This gives truckers the opportunity to negotiate unsafe sex easily, and they do. For example, one type of common sex work on long-haul routes was euphemistically referred to as the “lot lizard,” young women who move from truck to truck at truck stops, knocking on doors and offering sex for cash in the cabs of the trucks. These women are sometimes retained by the local truck stops and sometimes independent. Some of them exchange sex for transport, that is they need to move interstate so they pay for the trip by a night in a cab. This type of informal sex work is, classically, the type most associated with unsafe sex and least amenable to safe sex messages.
- Drug use: some truckers use a lot of speed to maintain their hectic schedules, especially if they have a young family to support or are new to the industry, and these guys may shift to injecting the drug, a high risk activity for HIV, though probably in the case of truckers sharing is uncommon and injecting in groups is unlikely. The risk, of course, is that they will share their needle and drugs with a sex worker, creating the classic combination of vectors for HIV
- Gay sex: all the truckers interviewed “knew someone” who has gay sex, but they all refused to identify the person in question as gay; the person in question was a trucker, and axiomatically truckers aren’t gay (it’s impossible). But men who have sex with men are the highest risk of unsafe sex, since they aren’t being accessed by community-focussed safe sex messages, and in recent years most HIV-related health promoters have been recognizing this problem and addressing it through more diverse and targeted safe sex messages. One of the messages of articles like this one are that the range of sexual behaviour people engage in is much greater than the range of easily definable human beings; but health promotion messages are much easier to broadcast successfully if targeted at easily identifiable categories of person (such as gay, sex worker, rugby player, doctor). It’s not the fault of health educators, but it’s often the people who fall through the cracks who are the most at risk. Truckers who define themselves aggressively as straight, but have sex with other men, are a classic example of this.
In addition to identifying these risk behaviours, the authors also, through the interviews, identified three key groups of truckers for whom safe sex messages could be, or needed to be, targeted:
- Highway cowboys: young, working very long hours at high intensity with few breaks, often taking speed, supporting a young family but also using sex workers and taking all sorts of drug-, sex- and driving-related risks, the highway cowboys were the key risk group who needed safe sex and safe injecting information pronto
- Old Hands: Men who have passed through the cowboy stage, learnt the ropes, have less responsibilities and a better grasp of how life works, these men were respected by other truckers and less likely to engage in extreme work and recreational activities. They might still see sex workers but were much less likely to take drugs or risks. These men are the best candidates for peer education outreach; that is, they can be taught to proselytize for safe sex and drug use
- Christian Truckers: highway cowboys who have found god and think the behaviour of other highway cowboys is reprehensible. I recall a quote from one trucker complaining that he couldn’t sleep because of all the sinful activity going on in his parking lot, and sneering at the lot lizards for their role in it. These guys are beyond risk, but not so well respected by their fellows that they could provide outreach or education
The tone of this article is consistent throughout; amused, but respectful of the research subjects and their particular needs. It manages to convey the authors opinion of the truckers’ attitudes to their own milieu, while maintaining a respectful distance and offering non-judgemental commentary on the public health issues. While the truckers themselves may say quite nasty things about the women who service them, the article refrains from judging the truckers’ opinions or from giving negative opinions about those women, while recommending practical and sensible suggestions that will improve the health of everyone involved. My main criticism of the content of this article is that a) it suffers from the usual problem of interview studies, that you don’t know how objective the interview component is, and the number interviewed is small; and b) it misses a chance to also describe injury-related health problems (the focus is very much on HIV). The latter is not a big deal in my opinion, and the former an inevitable problem with interview studies; but this one also has basic questionnaire data on risk behaviour to back it up. Also, the sample is a snowball-sample, I think, which is bad, but this is unavoidable with these kinds of studies – you can’t do a random sample of truckers.
Public Health Value
This is a classic example of the importance of social research for public health. It identifies high-risk behaviour and the groups of people who do it; fleshes out the culture underlying the risk-taking through interviews; and identifies the groups who can be most effective at changing it or are most resistant to change, as well as the key public health risks. It gives information for both sexual health practitioners and health educators, and gives basic data on what the risks are. Note, too, that although it might seem amusing and trivial, the topic here is, fundamentally, deadly serious. HIV is a serious disease and truckers (and the sex workers with whom they inevitably interact) are a key vector for its transmission. HIV probably entered France on trucking routes from Africa, and probably also Haiti; it has spread rapidly through Africa and no doubt truckers were a key vector of transmission. In the USA, where there are areas of high HIV prevalence, truckers are one of a small number of key vectors by which the disease can break out into a wider community. Truckers travel from high- to low-HIV prevalence areas, engage in multiple risk behaviours, and have families with whom they practice unsafe sex. This makes them very important to understand, but their particular workplace culture also makes their community very hard to penetrate. This paper achieved that through careful, meticulous research, and deserves credit for providing a powerful insight into a very hard to reach group.
Stratford D, Ellerbrock TV, Akins JK, Hall H. Highway cowboys, old hands, and Christian truckers: risk behavior for human immunodeficiency virus infection among long-haul truckers in Florida. Social Science & Medicine, 2000: 50(5); 737-749.
Autoerotic fatalities with power hydraulics
Again, I’m reporting on this article from memory, but I think the abstract speaks for itself:
We report two cases in which men used the hydraulic shovels on tractors to suspend themselves for masochistic sexual stimulation. One man developed a romantic attachment to a tractor, even giving it a name and writing poetry in its honor. He died accidentally while intentionally asphyxiating himself through suspension by the neck, leaving clues that he enjoyed perceptual distortions during asphyxiation. The other man engaged in sexual bondage and transvestic fetishism, but did not purposely asphyxiate himself. He died when accidentally pinned to the ground under a shovel after intentionally suspending himself by the ankles. We compare these cases with other autoerotic fatalities involving perceptual distortion, cross-dressing, machinery, and postural asphyxiation by chest compression.
Unlike the previous article, this article is presented in an entirely professional and medical tone, just like reading medical notes. I can still recall reading a phrase like, “The family were somewhat surprised to discover the case’s sexual habits,” presented as if the sexual habit were completely normal and merely unknown to the wife, in a dry tone that doesn’t contain any indication that the activity in question is, well, unusual. And it’s pretty likely that it was a family member who discovered the victim in both cases – and in the latter I seem to recall there was a complex arrangement involving a broomstick to the anus and some rubber tubing to control the digger machinery. This is not the sort of thing you want to see when you go down to the shed to collect your husband for lunch.
The dry tone provides its own humour, but at the heart of both stories is an unavoidable tragedy of forbidden love, shame, stigma and auto-eroticism that would leave Shakespeare flabbergasted. Truth is indeed stranger than fiction, and presenting it as a medical case report just makes it … stranger.
Public Health Value
Pretty limited, really, but it’s worth noting that there is a lesson in these deaths that extends to much more risky and epidemiologically relevant tales. Shame, stigma and the need to hide one’s inclinations don’t stop one from doing them, they just make one do them secretly and dangerously. Unable to discuss one’s habits, one hides them, works out how to do them oneself and, if doing them unsafely is possible, one learns to do them unsafely. This is what these two men did, with sad and fatal results. This is why in public health we should always be concerned about the health consequences of an activity for the person, rather than what the activity says about the person themselves. Which isn’t to say that personally we should approve or disapprove of someone fucking their tractor; but our public health concern is to stop them dying, not to stop them doing it.
In this case, of course, there was no hope that we could help these people share and control the risk of their behaviour, since sharing inevitably involved loss of family connections, a powerful inhibitor to honest discussion of “deviant” behaviour. But it tells us a story about exactly what the consequences of secrecy are, and reminds us that if there is a way that we can reasonably prevent people from experiencing these costs through revealing their behaviour, we can make a huge difference to the risks they face and the risks they inflict on others. So next time you feel like judging someone else’s victimless behaviour, ask yourself: “how would I feel if it was me fucking my tractor, and my jury-rigged shovel control had broken?”
O’Halloran RL, Dietz PE. Autoerotic Fatalities with Power Hydraulics. Journal of Forensic Science. 1994 Sep;39(5):1143-4.