Behavioral Studies of Female Sex Workers in China: A Literature Review and Recommendation for Future Research
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- Hong, Y. & Li, X. AIDS Behav (2008) 12: 623. doi:10.1007/s10461-007-9287-7
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Commercial sex plays a critical role in the heterosexual transmission of HIV in China. This study reviews behavioral studies in English literature on female sex workers (FSWs) in China from 1990 to 2006. Existing studies indicate that FSWs in China are young, mobile, most of them have both commercial and non-commercial sex partners; they have low rates of consistent condom use and high rates of STD infection. Some FSWs are also engaged in drug abuse. There is a great variation of sexual practices and HIV risks among FSWs across different work settings. Limited numbers of intervention studies have reported positive effects on increasing condom use and/or decreasing STD infections. Literature gaps and lessons learned from existing studies are identified and future research needs are discussed. Future behavioral intervention programs need to be multi-faceted and incorporate environmental and structural factors for different groups of FSWs.
KeywordsFemale sex workersBehavioral StudiesReviewChina
While the actual HIV seroprevalence in China remains uncertain, the current official estimate of number of persons infected with HIV exceeds 650,000 (China Ministry of Health, UNAIDS, and WHO 2006) and the HIV epidemic is in the stage of “rapid spread” (Grusky et al. 2002; Qian et al. 2005). Even though intravenous drug use (IDU) and commercial blood/plasma collection were historically the main sources for the HIV infection in China, infection through sexual transmission is growing the fastest, accounting for nearly 50% of new infections in 2005. Overall, sexually transmitted cases have increased from 7.2% in 2002 to 43.6% in total infections by the end of 2005 (China Ministry of Health, UNAIDS, and WHO 2006). Public health experts have warned that sex workers and their clients may serve as the “bridge” populations linking high risk groups (such as drug users and STD patients) to the general population (Hesketh et al. 2005; Tucker et al. 2005; Yang et al. 2005a).
Commercial sex has been a visible part of the Chinese culture throughout history, but its public health consequences were not documented until the 20th century (Hershatter 1993). After the Communist Party took power in 1949, commercial sex and STDs were depicted as result of imperialism and western influence, and were projected to be eliminated under the new socialist regime (Cohen et al. 1996; Cohen et al. 2000). Massive propaganda and radical measures were implemented, including mass screening and closure of all brothels. All sex workers were sent to reeducation centers, where they received therapy for STDs and general education with emphasis on literacy and basic working skills. These campaigns were considered to have been successful and China declared in the early of 1960s that it had successfully eradicated STDs and commercial sex (Abrams 2001; Cohen et al. 1996).
However, commercial sex has resurged in China since the 1980s when China began its economic reform. The resurgence of commercial sex was driven and reinforced by economic disparities, greater freedom of population movement, increased disposable income, and the changing sexuality (Gil et al. 1996, 2002; Hershatter 1996; Tucker et al. 2005; Zhang et al. 1999). Commercial sex is still illegal in China; female sex workers (FSWs) and their clients are subject to fines and incarceration (e.g., women’s reeducation center) if arrested. Depending on the different definitions and methods of estimation, estimated numbers of FSWs vary from 1 million to 10 million (Huang et al. 2004; Pan et al. 2004; Schafer 2003). According to a nationwide survey in 2000, 6.4% Chinese men aged 20–64 years had engaged in commercial sex at least once in their lives (Pan et al. 2004). Concurrent with the resurgence of commercial sex, STD infections have also increased dramatically, with annual cases increasing by 147 fold from 1985 to 2000 (Lin et al. 2006). The overall prevalence of HIV among the FSWs in sentinel surveillance sites was 1%, and was as high as 6.7% in some areas (China Ministry of Health 2004).
One of the factors that drive the rapid spread of HIV in Asian countries is the transmission from sex workers to their clients and to the general population (Rojanapithayakorn 2006). It is believed that the future of the HIV epidemic in China depends to a great extent on whether China can find the answer on how to prevent a drug-driven epidemic from becoming a sex-driven one (Anonymous 2005). In search of this answer, many studies have been conducted to identify the HIV risks and explore effective prevention intervention approaches among various groups of FSWs. In 1991, Gil first reported the increasingly important role of heterosexual transmission in China’s HIV epidemic, even though the official number of HIV cases was quite low at the time (Gil 1991). Gil and colleagues subsequently published one of the first studies on FSWs in contemporary China, using prison records of incarcerated FSWs (Gil 1994; Gil et al. 1996). Since then, more and more studies have focused on this high risk population, especially regarding their sexual risks and their impact on China’s STD and HIV epidemics. However, to date there has been no systematic review of these published studies.
Given the critical role of commercial sex in heterosexual transmission of HIV in China, it is important to examine the existing evidence of HIV risk factors among this high risk and potential bridging population and to make recommendations for future intervention and prevention efforts. Accordingly, this study systematically reviews English literature of Chinese FSWs from 1990 to 2006, with the following objectives: (1) describe the demographic profile of FSWs in current China; (2) examine FSWs’ sexual practices and HIV-related behaviors and associated social and environmental factors; and (3) discuss gaps in research from existing literature and make recommendations for future behavioral and intervention studies.
Materials and Methods
A comprehensive literature search was conducted to identify studies that meet the following selection criteria: (1) peer-reviewed studies published in English language journals from 1990 to 2006, (2) studies that focus on FSWs in China (mainland), (3) empirical studies that report at least one of the following outcomes: sexual practices, condom use, and HIV or STD infection.
Studies were retrieved from the following electronic databases: PubMed, AIDSLine, EBSCO, PsycInfo and FirstSearch. Each database was searched using the following key words, alone or in combination: China, sex workers, prostitutes, entertainment workers, prostitution, commercial sex, and HIV risks. In addition, we searched and retrieved articles from reference sections of review articles on HIV/AIDS in China (Grusky et al. 2002; Qian 2005; Tucker et al. 2005; Yang et al. 2005a; Yu et al. 1996).
A total of 26 articles that met the above selection criteria were identified, among which 20 were quantitative studies and six were qualitative studies. We integrated herein both quantitative and qualitative data to provide a review of FSWs’ demographic characteristics, sexual practices, condom use, HIV or STD infection, other HIV-related risks, and related social and cultural factors.
Summary of quantitative behavioral studies on female sex workers (fsws) in China
Study time, location and sampling
HIV or STD infection rates
Drug use and other risks
1988–1990. Sichuan Province. N = 724, institution sample.
Median age: 22.7 year.
Never married: 59%
6 year Edu: 43.3%.
From rural: 41.5%.
factory workers: 20%;
drivers: 17%; officials: 8%.
History of any STD: 48.8%;
1988–1990. Sichuan and Guizhou Provinces. N = 707, institution sample.
Age < 25 year: 44.6%;
Never married: 54.2%;
From rural: 53.2%.
History of NG: 85.4%;
1990, Chengdu City, Sichuan Province. N = 626, community sample.
14–24 year old: 76%.
Never married: 75.6%.
9-year Edu: 46.6%.
History of NG: 77.2%
van den Hoek (2001)
Guangzhou City, Guangdong Prov. N = 966, community sample.
Mean age: 25 year.
Median Edu-year: 9 year.
Median # of sexual clients: 7.
Had stable partner in past 12 month: 41.3%.
Had casual partner in past 12 month: 24%.
w. client last 2 month: always: 30.1%; never: 4.9%.
w. stable partner last year: always: 8%; never: 53%.
Current HIV+: 1.4%;
genital warts: 7.4%.
IDU since 1990: 6.9%.
Freq. drink beer w. clients in past 2 month: 5.9%.
2000, Beijing City. N = 69, community sample.
Age ≤ 25 year: 72%.
Never married: 68.1%.
≤ 9 year Edu: 69.5%.
From rural areas: 62.3%.
Varied by work venue Age of start sex work: 21.38∼23.79 year.
# of clients/week: 1.77∼5.16.
Charge per client: 201∼921 yuan.
Varied by work venue. Always or freq. had condoms available: 35∼65%.
Stable partner never used condoms: 52%, used in past month: 25∼67%.
History of NG: 6%.
2000, Baise City, Guangxi Autonomous Region. N = 482, community sample.
Median age: 20 year.
Never married: 82%.
From local: 65%.
Median age of sexual onset: 20 year.
Median # clients last month: 10.
Last year, only sex w. clients: 32%;
Partner = IDU: 5%; not known: 12%.
W. spouse/finance last year: always: 9%; never: 59%.
w. BF/casual aquain. last year: always: 13%; never: 46%.
w. clients last year: always: 17%; never: 27%.
Self-report STD in last year: 21%.
Current HIV+: 0
Current syphilis: 4%
Life-time drug use: 8%. IDU: 7%; among whom, 85% shared needles and 97% exchanged sex for drugs in the last year.
1998, Shenzhen City, Guangdong. N = 701, institution sample.
Age < 25year: 68.5%.
Never married: 67.4%.
0–5 year Edu: 32.4%;
6–8 year Edu: 47.7%.
From local: <10%.
1 client/day: 41%;
2 clients/day: 16%;
≥3 clients/day: 11.3%.
Not report: 32.1%.
Mainland client only: 25.5%; Hong Kong client only: 17%; Mixed client: 50%.
w. client: always: 68.5%; not always:
21.7%. w. “STD clients”: always: 35.4%;
not always: 13.4%.
Had STD check-up: 43%.
History of STD: 14.5%.
1998–1999, Guangzhou City, Guangdong. N = 966, community sample.
Mean age: 25 year.
Mean Edu year: 9 year.
Mean age of sex work onset: 22.9 year.
Median length of sex work: 12 month.
Median workdays/w: 5
Median # clients/week: 7.
Had stable partner in past 12 month: 34.7%.
Consistently condom use in past 2 month: 30.1%.
History of STD: 8.5%.
IDU since 1990: 6.9%.
1997–2000, Fortune County, Hainan Province. N = 221 (1997), community sample.
Mean age: 19 year.
Never married: 90%.
Mean Edu year: 7 year.
Ethnic minority: 21%.
Median age of sexual onset: 18 year.
% of never married had pregnancy: 15.8% (N = 198).
Ever had abortion: 13%.
History of STD: 10%.
Ibid. N = 117 (2000, post-intervention)
Condom use in last sex act pre-post intervention: 50–>70%.
Condom use in >50% of sex acts pre-post intervention: 40–>80%.
1999, Wuhan City, Hubei Province. N = 147, community sample.
Mean age: 22.7 year
19.7% had sex with clients >7 times/week.
51.7% used condoms consistently.
HIV: 0. HSV2: 21.6%.
Drug user: 5.8%.
2002, Beijing City and Nanjing City. N = 40, community sample.
Mean age: 23.9 year.
≤9 year Edu: 71.8%.
Never married: 76.9%.
Mon.income ≥ 800RMB: 75%.
Change jobs ≥1 per year: 65%.
From rural: 95%.
Age of sexual onset <20 year: 74.4%.
Sexual debut before marriage: 872%.
Stable partner has sex with others: 84.6%.
Consistent condom use in last 3 sex acts: 27.5%.
Discussed condom use with sexual partner: 62.5%.
Ever used drugs: 20%. Sold blood/ plasma last year: 10.3%. Got drunk last mon: 65%.
Depressed(CESD) ≥ 16: 50%.
2000–2001, Zhengzhou City, Henan Province. N = 621, community sample.
Age ≤ 19 year: 27%;
20∼24 year: 41%;
25∼29 year: 19.7%.
Never married: 66.7%.
≤8 year Edu: 55.2%.
Age of sexual onset:
≤14 year: 4%;
15∼19 year: 61.4%;
20∼24 year: 33.3%.
Median # of clients/week: 6.
w. clients always: 13.2%. # of sex services w/o using condoms/month:
History of STD: 19.8%.
Current HIV+: 0.3%.
History of IDU: 0.8%.
Recognized clients as drug user: 9.5%.
2004, Jinjiang City, Jiangsu Province. N = 299, community sample.
never: 2.66%; sometimes: 29.8%; always: 67.6%.
w. stable partners:
never: 53.2%; sometimes: 31.4%; always: 15.4%.
Hesketh et al. (2005)
2003, Yingjiang County, Yunnan Province. N = 84, community sample.
Median age: 17.8 year.
≤8 year Edu: 45%.
Ethnic minority: 73%.
Length of sex work: <1m: 18%; 1∼6 month: 57%; 6∼12 month: 21%; >12 month: 4%.
mostly local: 20%; mostly elsewhere: 36%; both equal: 27%. # of clients/week: 1–2: 23%; 3–4: 27%; 5–6: 21%; ≥7: 29%
History of STD: 13%
1999–2000, Kunming City, Yunnan Province.
N = 505, community sample.
Mean age: 25 year.
Had <secondary school: 81%.
From local: 30%.
Not use condom in >50%
sex acts: 54.8%.
CT: 58.6%; Tri: 43.2%; NG: 378%; Syphilis: 9.5%. HSV–2: 65.1%; HIV: 10%;
Drug users: 10%.
2004, H county, Guangxi. N = 454, community sample.
Mean age: 23.5 year.
Never married: 60%.
≤6 year Edu: 58.2%.
From rural area: 79.6%.
Ethnic Minority: 45%.
Mon.income ≤ 400RMB: 40%.
Mean age of sexual onset: 18.6 year.
Length of sexual work: 12.2 month.
Have a stable partner: 68.4%.
Mean # of client/week: ≤2: 80.6%; >2: 19.4%.
Condom use was strongly associated perceived level of support from gatekeepers.
Douching after sex with clients: 29.3%.
Douching after sex with stable partners: 19.1%.
W. stable partners:
never: 42.2%; sometimes: 49.4%; always: 8.4%.
History of STD: 19.4%. Current STD infection: 41.5%.
Ibid. N = 278 (post-intervention)
Had a stable partner: 72%.
Consistent condom use pre-post intervention:
Intervention: 34–>53%; Control: 16–>25%.
Rate of current STD infection pre -post intervention:
2004–2005, Xichang City, Sichuan Province, N = 343; community sample
Mean age: 23.7 year
Ethnical minority: 12%
Local residents: 38%
≤6 year Edu: 32%
Annual income < US$1220: 43%
From rural: 70%
Low-end workplace: 51%
Average charge per trade < US$12.2: 34%. Age of sex debut < 18: 36%.
Median age of sex work onset: 21 year. Median year of sex work: 1 year.
Had primary partner: 59%; Had unfaithful partner: 37%. # of trade last month < 10: 29%.
Median # of clients past 6 month: 80. Median # of new clients past 6 month: 70.
Consistent use last month: 54%; never use: 7.6%
Never use w. primary partners last month: 50%
C acuminatum: 1.5%.
Any STD: 20%
Drug users: 10%.
IDU past 3 month: 4%.
Summary of qualitative studies on female sex workers (FSWs) in China
Time & location
Study methods and samples
Brief domains of findings
1988–1990. Sichuan and Guizhou Provinces.
Ethnographic observations and interviews, prisoner data and secondary data (print media and official reports).
Proliferation of prostitution was driven by more political freedom, economic opportunities, and pursuit of individual goods. Given these, current control measures of prostitution (i.e. rehabilitation model) may not be effective approach for HIV prevention.
1997–1998. Jinghong, Yunnan Province.
Ethnographic observations and in-depth individual interview.
Sexual practices of FSWs represented the interactions of state policy, popular practice, and changing sexuality in China. Condom use by FSWs was under influence of the transition of health care system and market-oriented economy.
1997, Hainan Province.
Ethnographic observation and in-depth individual interviews.
N = 12. Community sample.
Awareness and motivation of sexual protection was low, misconception prevailed.
FSWs’ sexual practices were influenced by their managers’ opinions, relative status to their clients and partners, their economic status, traditional reproductive culture, birth control policy and changing attitudes on sex-related health.
2001, Ruili, Yunnan Province.
Focus group discussions and individual interviews.
N = 89 (FSWs and their managers). Community sample.
Median age: 19.4 year.
FSWs often acquired knowledge from their peers and self-medication was common. They were very stigma-cautious, and lacked essential skill to negotiate condom use. Many were from nearby villages but were reluctant to participate in organized activities.
2000–2001, 2 provinces in Southwest China.
Ethnographic observation and in-depth individual interviews.
N = 158. Community sample.
Median age: 20 year in towns, 23 year in suburb of city.
Brothel-based FSWs were heterogeneous by their work places, displaying considerable variation in the organization of life and work, relationships with managers and clients, ability to negotiate condom use, knowledge of STDs and HIV, and occupational identity.
In-depth individual interviews.
N = 40. Community and institution samples.
Age: ≥25 year old: >50%. Never married: 60%. ≤9 year Edu: 65%. Migrants: 62.5%.
Prevalence of unprotected sex varied across sex work venues and by FSWs’ relationship to pimps or managers.
Factors for unprotected sex included lack of HIV transmission knowledge, economic hardship, client refusal/coercion, and control by pimps or managers.
FSWs endorsed the need for HIV or STD prevention, but were suspicious of government programs.
Working Environment of Sex Workers in China
The FSWs in China are called “Xiaojie” (literally translated as “miss” in English) (Hong et al. 2006). The existing literature suggested tremendous heterogeneity among FSWs in China in terms of their working environment. Several researchers in China have classified FSWs into a multi-layer spectrum (Huang et al. 2004; Ruan et al. 2006). “High-status” sex workers, who work in high-class dance halls and clubs, or who cater as “call girls” to businessmen, are often able to charge high prices for their services and work in private settings. At the other end of the spectrum are “street-walkers”, who are often considered to be at the very bottom of the hierarchy (Rogers et al. 2002). Some sex workers only work on a part-time or occasional basis to supplement their income from legitimate employment (i.e., indirect sex workers). For example, a recent study among female rural-to-urban migrant workers in Beijing and Nanjing suggested that 6.3% of them had ever exchanged sex for money (Yang et al. 2005b). In addition to the usual form of one-time sex trade, some women provide long term (several months, or even years) sex services to men, known as “Bao-Er-Nai” (meaning “keeping a second wife”). The payment to these women is not based on each sexual encounter but the demands of the long-term relationship. For example, the man may pay for other expenses such as the woman’s housing and stipend (Liao et al. 2003).
While some FSWs are street-based or freelance, the majority of them encounter their clients in entertainment establishments, in which FSWs differ substantially in terms of their working and living conditions (Xia and Yang 2005). Women in the “high-end” entertainment establishments (e.g., dance halls, night clubs, Karaoke bars) are normally not directly employed by the owners of the establishments, but are allowed to work there to attract customers who often come to the establishment to dance, sing, drink, and/or eat first. In hotels and restaurants, some women work as bar maids or waitresses, but also provide sex services for which the clients pay extra money directly to the women (Huang et al. 2004). In contrast, many FSWs work in hair salons, hair-washing rooms, massage parlors, bathhouses, or small road-side restaurants (e.g., “low-end” establishments) that have the reputation of providing sexual services in China (Li et al. 2006; Ruan et al. 2006). Theses establishments typically pay the women a minimum monthly base wage; the women receive a proportion of the fees customers pay to the managers for the sexual services they provide.
FSWs’ Demographic Profiles
Studies found that most FSWs admitted entering commercial sex voluntarily. The primary motivation was money (Gil et al. 1996; WHO 2001). Many women were attracted by its quick financial return and chose sex work as a mean to support families. Some FSWS were practicing “survival sex” as a result of poverty and limited employment opportunities. A small portion of women (particularly young or underage girls) were deceived or forced into sex trade against their wills, and some women entered the profession after failure of marriage or personal relationship (Gil et al. 1996; Liao et al. 2003).
Almost all FSWs participated in these studies were in their teens or early twenties, with only primary school (6 years of schooling) or junior high school (9 years of schooling) education. Most of them were never married, and many were unemployed or grew up in rural areas before engaging in commercial sex. A majority of the studies identified their participants primarily migratory, with the proportion of migrants ranging from 62.3% to 95%. Two studies conducted in Guangxi and Yunnan, however, reported that most of the participants (65% and 80% respectively) were local residents (Hesketh et al. 2005; Qu et al. 2002). Four studies reported FSWs’ income, which varied by size of the cities. FSWs in big cities reported having relatively higher incomes than their counterparts in smaller cities or rural areas. For example, FSWs in Beijing reported an average income of 1,000 Yuan (about $125) a week (Rogers et al. 2002). In contrast, 40% of FSWs in a rural area of Guangxi reportedly earned less than 100 Yuan (about $12) a week (Yang et al. 2005c).
Sexual Practices and Condom Use
Most FSWs had their first sexual encounter in their late teens or early twenties, and their age of starting commercial sex was generally within 1 or 2 years of sexual onset (e.g., Ruan et al. 2006). Most of these women reportedly had been in commercial sex for about 1 year or less. The average number of clients for FSWs was 1–2 per day. They identified their clients in a range of occupations/identities such as self-employed, governmental officials, businessmen, local residents, truck drivers, and overseas tourists. The majority of FSWs had both commercial sex partners and non-commercial partners (i.e., stable sexual partners). Many of them (37–85%) reported that their stable partners also had sex with others (Ruan et al. 2006; Yang et al. 2005b).
Most FSWs reported low rates of condom use with their stable partners, with nearly half never using a condom with their stable partners (Pingmin et al. 2005; Qu et al. 2002; Ruan et al. 2006). The majority of studies reported a rate of consistent condom use with clients between 13% and 54%, which was higher than that with stable partners (8∼15%). Some FSWs even did not always use a condom when they had sex with clients with STDs (e.g., clients who were perceived to have STD infection) (Lau et al. 2002). Several studies reported that FSWs’ sexual risks were associated with environmental factors such as work places and perceived support from gatekeepers (e.g., managers or owners of the establishments) (Hesketh et al. 2005; Qu et al. 2002; Rogers et al. 2002; Yang et al. 2005c).
HIV or STD Infection
Six studies reported rates of HIV infection among samples. Among them, one study reported a high rate of HIV infection (10.3%) among FSWs recruited from women’s reeducation centers or STD clinics (Chen et al. 2005). The other five studies that used community samples reported low rates of HIV ranging from zero to 1.4% with a mean of 0.5% (Ding et al. 2005; Qu et al. 2002; Ruan et al. 2006; van den Hoek et al. 2001; Wei 2004). Reported STD rates were much higher than HIV rates; and institution samples reported higher STD rates than community samples. For example, Gil et al. (1996) reported STD infection history of 48.8% among FSWs from a women’s reeducation center in Sichuan and history of Gonorrhea of 85.4% among FSWs from women’s prisons. Studies based on community samples revealed self-reported history of STD infection ranging from 8.5% to 19.8%. Five studies reported biologically-confirmed rates of current STD infection ranging from 13% to 41.5%, which were higher than self-report STD history. For instance, in a study conducted among 454 FSWs in Guangxi, 19% of the women reported a history of STD infection, but 41% were tested to be infected with at least one STD (Wang et al. 2005).
Drug Abuse and Other HIV Risks
Seven studies reported drug use behaviors among FSWs. Life time drug use prevalence ranged from 5.8% to 20% and IDU ranged from 0.8% to 7% (Ding et al. 2005; Ma et al. 2002: Qu et al. 2002; Ruan et al. 2006; van den Hoek et al. 2001; Wei et al. 2004; Yang et al. 2005b). Among these drug-using FSWs, many used commercial sex to support their drug habits. Many FSWs were also engaged in other risk behaviors, such as alcohol use, or selling blood or plasma (Qu et al. 2002; van den Hoek et al. 2001; Yang et al. 2005b). One study reported that more than half of the FSWs had elevated level of depressive symptoms (Yang et al. 2005b).
Social and Cultural Factors
Existing studies, particularly qualitative studies, suggested that proliferation of commercial sex in China was driven by increasing economic disparities, individual freedom, and liberation of sexual attitudes (Gil 1994). FSWs were very heterogeneous in their HIV-related behaviors, displaying considerable variations in the conditions of their life and work (Hesketh et al. 2005; Huang et al. 2004; Xia and Yang 2005). They were very stigma-cautious, and had high degrees of misconceptions regarding HIV transmission (Wong 2003; Wong and Wang 2003; Xia and Yang 2005). Longer duration of sex work, working at lower-end establishments and having unfaithful primary sexual partners were found to be independently associated with Syphilis infection among FSWs (Ruan et al. 2006). Both qualitative and quantitative data also suggested that HIV-related risk behaviors of FSWs were not solely under the control of FSWs themselves, who usually had low motivation and limited power in their condom use negotiation (Huang et al. 2004; Yang et al. 2005c). In addition, the sexual practices of FSWs were largely influenced by their economic status, their working environment, and the attitudes of their gatekeepers (Huang et al. 2004; Liao et al. 2003; Yang et al. 2005c). FSWs’ commercial sexual practices were also impacted by the legislature (e.g., illegality of commercial sex), state policies (e.g., reproductive and family planning policy), transition of health care system, and the market-oriented economy (Gil 1994; Wong 2003). These studies called for a holistic approach in studying FSWs, using multi-faceted interventions incorporating social and environmental factors to reduce HIV risks among FSWs.
Our extensive search of English literature only identified three intervention studies, with two of the studies using quasi-experimental design. The first study provided preventive education and STD testing and treatment to FSWs in a hospital of Guangzhou. This study reported a positive intervention effect, with an increase in consistent condom use and a decrease in STD incidence over a 6-month period (Ma et al. 2002). The second study was a non-experimental community-based condom use promotion study among FSWs (“hospitality girls”) in a rural town of Hainan Province. This study reported an increase in condom use over a 2-year period (Liao et al. 2006). The third study was a randomized trial of voluntary counseling and testing (VCT) intervention among 400 FSWs in a rural county in Guangxi. In the 6-month follow up, intervention group reported higher rates of condom use and lower rates of STD infection than the control group (Li et al. 2006).
Existing published studies in the English literature reveal a profile of FSWs in China: they were young, mobile, and low-educated. Most of them were rural residents or unemployed before entering this profession. They initiated sex and engaged in commercial sex at a young age. Many of them also had stable or non-commercial partners, but about half of them never used a condom with their stable partners. Consistent condom use with clients was low, ranging from 15% to 35%. HIV infection rates reported among FSWs in these studies (0–1.4%) were comparable to data from national sentinel sites, which reported an average HIV infection rate of 1% (China Ministry of Health 2004). However, existing studies reported alarmingly high rates of STD infection among FSWs, either currently or in the past. Some FSWs were also engaged in other HIV risk behaviors such as substance abuse and selling blood/plasma. Existing data did not reveal a visible temporal trend in FSWs’ HIV-related behaviors, including condom use and HIV/STD infection. Studies published before 2001 mainly focused on incarcerated FSWs and self-report history of STDs, but not their condom use behaviors and current infections. Studies published from 2001 to 2006 were primarily conducted in community settings and reported more behavioral indicators and current infectious status.
Chinese FSWs’ HIV-related behaviors are similar to those observed in some other Asian countries such as Viet Nam and Indonesia (Joesoef et al. 2000; Minh et al. 2004). Condom use rates among Chinese FSWs were much lower than those reported in Thailand and Cambodia (Buckingham et al. 2005; Monitor AIDS Pandemic 2005). Such variations may be due to differences in social system (e.g. sexual culture, economic development), stages of HIV epidemics, and local HIV intervention efforts (Ruxrungtham et al. 2004).
While the published studies reviewed in this study have provided valuable information on FSWs in China regarding their risks of HIV infection and transmission, there are some limitations in the existing literature, which also represent the lessons learned over the past 16 years and the gaps in the empirical endeavor to understand HIV risks and the related behavioral and structural factors among the FSWs.
First, nearly all these studies were based on institution samples or women working at entertainment establishments or personal service sectors. Due to the illegal and clandestine nature of commercial sex in China, women’s reeducation centers and entertainment establishments may be the most convenient venues to recruit participants. However, institution samples may not be representative of the general FSW population, because only a very small proportion of FSWs have ever been sent to the reeducation centers (Li et al. 2002). Furthermore, FSWs are a heterogeneous group and operate in a multiple-layer hierarchy (Huang et al. 2004). FSWs working in the entertainment establishments are in the middle of the spectrum and may be the most accessible group. We know little about the FSWs in either the higher ranks (e.g., call girls, second wives, hotel courtesans) or the lower ranks of the hierarchy (e.g., street walkers, sex workers in construction sites). In addition, many FSWs in these studies reported that they had been working as FSWs for 12 months or less. It is likely that only the younger, inexperienced, and more vulnerable FSWs were sampled, and those who were more experienced were missing from the picture. Thus, future research efforts need to study FSWs in other categories as well as more experienced FSWs.
Second, the geographic locations of existing studies were disproportionately concentrated in Southwest and South China, large cities, or economically booming areas, which are most affected by the HIV epidemic. But commercial sex is so “flourishing” that it has spread from big metropolitans to small towns and even rural areas. As some Chinese researcher described, “there is no red-light zone, but red lights are everywhere” (Zhang 1997, p 16). Because of the wide proliferation of commercial sex and the considerable cultural and social variation across different regions in China, it is important to study FSWs in other areas of China and to study FSWs in rural areas or resource-poor settings.
Third, the majority of studies used data collected from cross-sectional surveys and retrospective data (e.g. prison records). Similar to situations in other countries, there is a lack of studies using other methodologies such as prospective or longitudinal design (Vanwesenbeeck 2001). Even though it is a challenge to follow a hard-to-reach and highly mobile population such as FSWs, the complexity of their sexual practices and networking and their high vulnerability to various health risks merit further efforts to study this population prospectively or longitudinally.
Fourth, limited data are available regarding FSWs’ partners (commercial or non-commercial partners). As documented in studies in other countries, male partners play important roles in FSWs’ sexual behaviors, and the male partners themselves represent a high risk population of HIV infection and transmission (Basuki et al. 2002; Ford et al. 1998). Thus, future studies are needed to examine HIV/STD-related risks among FSWs’ clients and stable (or non-paying) partners as well as their roles in FSWs’ risk behaviors and risk reduction.
Fifth, a few of the existing studies employed biomarkers (e.g., current HIV or STD infection) as outcome measures while the majority have relied on self-reported history of STD infection or other behavioral outcomes (e.g. condom use). Self-reported data are subject to many potential biases, which include errors of recall and socially desirable responses; previous studies suggested that biologically confirmed STD infection rates were much higher than self-report rates. Therefore, it is important to use biomarkers in future studies among FSWs in China. We particularly recommend using STDs as a surrogate of HIV infection, as the prevalence of HIV infection among FSWs in China may not be high enough (e.g., 0–1.4% in community samples) to allow a meaningful examination of the HIV infection in a cost-efficient manner.
Sixth, there is high variation in rates of consistent condom use (e.g., 13–54%) among FSWs and their sexual clients. This variation could be a result of variation in both sampling and measurement. For instance, the majority of studies measured FSWs’ condom use with clients and/or stable partners by using overall frequency in multiple categories (e.g., never, sometimes and always). In addition, different recall periods were employed (e.g., last three sex episodes, past month, past 2 months, past year, and lifetime). For a meaningful comparison of condom use behaviors across samples or over time, it is critical to establish a standardized, reliable, and comparable measurement of condom use in the future studies of FSWs in China. We in particular recommend a measure of consistent condom use (e.g., 100% use) in a relatively short time frame (e.g., last three sexual episodes or previous month) to increase the accuracy of measurement and comparability of findings from different studies.
Seventh, previous studies have suggested a potential overlap between commercial sex and drug abuse. The potential mixture of commercial sex and drugs has been considered as the main drive of China’s future HIV epidemic (UNAIDS 2005). Existing studies have focused primarily on FSWs’ sexual practices and condom use, with insufficient data collected regarding FSWs’ drug use behaviors including injection drug use. Future efforts are needed to examine the prevalence and mechanism of mixture of commercial sex and drug abuse by studying the drug use among FSWs and their clients as well as commercial sex (e.g., exchange sex for drugs) among female drug users.
Eighth, data on FSWs’ mental health is also limited. Despite their widely-recognized stigmatized status, there is scarcity of data on their mental health, experience of violence (e.g, domestic violence, intimate partner violence, or sexual violence), access to health care, and how these psychosocial factors affect their HIV-related behaviors. Millions of FSWs in China should not be viewed as just a HIV high-risk population; their psychological wellbeing and human rights also deserve more public health attention.
Ninth, as recognized in most of the existing studies, FSWs sexual behaviors (including HIV-related risk behaviors) need to be analyzed within the complex social and cultural context. There is a lack of systematic studies on how social and environmental factors affect FSWs’ HIV-related behaviors. Although some of the qualitative studies have attempted to address these issues (Huang et al. 2004; Liao et al. 2003; Rogers et al. 2002; Xia and Yang 2005), these studies were generally limited in numbers and scopes.
Finally, there is an urgent need for effective interventions that are informed by findings from these behavioral studies. In our literature search, we located only three intervention studies, all of which showed some degrees of success in increasing condom use or decreasing STD infections. In the past two decades, HIV prevention intervention programs that incorporate social and cultural factors have made tremendous contributions in the combat of HIV pandemic throughout the world. However, few of these successful theory-based behavioral prevention intervention studies have been adapted in China for various vulnerable and at-risk populations, including FSWs and their partners. Given the illegal nature of the sex work and the heterogeneity of the FSWs in China, many important research questions related to prevention intervention efforts remain to be studied in future research, including the methods to reach and retain FSWs (and their sexual partners) for the intervention efforts, the willingness of FSWs to participate in behavioral interventions, the psychosocial and structural barriers to behavioral interventions, the appropriateness of various Western-based theories of behavior and behavioral changes in the Chinese cultural settings, and the long-term sustainability of successful efforts.
In summary, FSWs’ high risks and vulnerability, as demonstrated in this review, call for more swift and firm actions. The heterogeneity of the FSW population suggests the need for culturally appropriate and multi-faceted strategies targeting different groups of sex workers based on their varying characteristics, including current sexual practices and work conditions. Future studies, with more rigorous research methodologies, are needed to focus on environmental factors (e.g., partners, gatekeepers, workplace, community and culture) and structural factors (e.g., policy, heath care system, law enforcement and legislature) associated with FSWs’ HIV risks, and to explore or evaluate ways to utilize these factors in designing and implementing effective and culturally appropriate HIV/STD interventions among FSW.
Accompanying these future research needs are the challenges faced in studying FSWs in China. Because of the illegal nature of commercial sex in China, it is difficult to access and retain these hard-to-reach groups and to study their clients and stable partners. The privatization of health care in China and the severe stigma against FSWs have further limited their access to adequate and timely health care (Hyde 2000; Wong and Wang 2003). Because it may be unrealistic to expect a rapid policy change in the near future at the central government or legislators towards commercial sex in China, any future HIV/STD prevention and intervention efforts targeting FSWs in China should emphasize both stigma reduction and empowerment at the community level. The HIV prevention efforts should reach gatekeepers, clients, partners, health care providers, policy makers and law enforcement agencies. It is also critical to mobilize the community resources (e.g., establishments, gatekeepers, local government) to empower these women. These stigma reduction and empowerment efforts should include the awareness of FSWs’ living conditions and psychological needs, protection of FSWs’ basic rights, access to affordable health care including prevention care, social marketing of condoms, and training of alternative job skills (Jana et al. 2004; WHO 2005).
This study is supported in part by a grant from the NIH Office of AIDS Research (R01MH064878-3S1). The authors wish to thank Dr. Ambika Mathur and Ms. Joanne Zwemer for assistance in preparing the manuscript.