1991). Migrant workers tend to be young, uneducated, and from developing countries. They and their families have limited access to health care because of their frequent relocation, language and cultural barriers, and limited economic resources (Bechtel et al., 1995). Traditionally, there have been distinct patterns of movement for migrant workers: north and south along the East and West Coasts and from Texas up through the Midwest. Currently, however, many migrant workers do not follow these patterns but criss-cross the country seeking work (Dougherty, 1996). Among migrant workers, men who are single or not accompanied by their families are at greatest risk for STDs. In some areas, it is common practice for sex workers to visit migrant camps for men and have sex with many men (Oscar Gomez, East Coast Migrant Health Project, personal communication, March 1996). STDs persist in migrant populations because of cultural influences against open discussion of sex and STDs, language barriers, lack of access to health care, and general lack of understanding of disease transmission (Smith, 1988; Bechtel et al., 1995). Social and cultural taboos make discussion of STDs uncomfortable for many migrant workers. For example, there is a reluctance to use condoms or request the use of a condom among migrant workers because there is an implied aspersion that the partner is not trustworthy (Bobbi Ryder, National Center for Farm Worker Health, personal communication, March 1996).

Secrecy as a Contributing Factor

Many of the obstacles to prevention of STDs at both individual and population levels are directly or indirectly attributable to the social stigma associated with STDs. It is notable that although there are consumer-based political lobbies and support groups for almost every disease and health problem, there are few individuals who are willing to admit publicly to having an STD. STDs are stigmatized because they are transmitted through sexual behaviors. Although sex and sexuality pervade many aspects of our culture, and sexuality is a normal aspect of human functioning, sexual behavior is a private—and secret—matter in the United States.

The committee uses the word "secrecy" in this report to describe certain aspects of sexuality in the United States. By the word "secrecy," the committee includes both the passive by-product of the inherent difficulties of discussing intimate aspects of life and the ongoing efforts by some groups to prevent open dissemination of information regarding sexuality and its health consequences. In this section, the committee summarizes the basis for the stigma surrounding STDs, the reticence to deal openly with sexual behaviors, and the impact of these two factors on preventing STDs.

Sexuality and Secrecy in the United States

Perhaps more than any other aspect of life, sexuality reflects and integrates



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