HIV/AIDS Risk Among Brothel-Based Female Sex Workers in China: Assessing the Terms, Content, and Knowledge of Sex Work : Sexually Transmitted Diseases

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HIV/AIDS Risk Among Brothel-Based Female Sex Workers in China: Assessing the Terms, Content, and Knowledge of Sex Work

Huang, Yingying MA*; Henderson, Gail E. PhD; Pan, Suiming MA*; Cohen, Myron S. MD

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doi: 10.1097/01.olq.0000143107.06988.ea
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THE SPREAD OF HIV IN China depends on overlapping epidemics, including intravenous drug users (IDUs), former plasma donors, men having sex with men, and the heterosexual population, including female sex workers (FSWs).1 Although HIV was first reported in China in IDUs,2 sexual transmission is rapidly increasing.3 The magnitude of spread of HIV in the heterosexual population depends largely on biologic and behavioral factors,4 as well as social forces unique to China. Extensive use of FSWs by Chinese men from all social classes5,6 and the rapid spread of classic sexually transmitted diseases (STDs) with high prevalence in FSWs7,8 greatly increase the risk of HIV transmission.

Sex work in China has a long and complex history, greatly affected by the political and economic changes in China during the 20th century.9,10 At the time of the Communist victory in 1949, sexually transmitted diseases (STDs) were very common and commercial sex was at least one driving force. Through massive public health efforts between 1954 and 1964, STDs and prostitution were reported to be virtually eliminated.11 However, during the past 25 years, China's open door policy and economic reforms have been accompanied by a remarkable resurgence of commercial sex. The prevalence of STDs and HIV in this population8 suggests a critical need for prevention efforts. The current study was undertaken to investigate how brothel-based sex work is organized to develop recommendations for prevention activities focused on FSWs in China.

Materials and Methods

Traditionally, the hierarchy of prostitution in China has ranged from high-ranking courtesans to employees in “flower-smoke room” brothels.10 Currently, there are at least 7 categories of FSWs,12 differentiated by work organization and employment status, income, and demographic characteristics (Table 1). The majority of female sex work is brothel-based, represented by categories 3 to 5, whereas categories 6 to 7 include freelance or street work, for which accurate estimates are difficult.

Categories of Female Sex Work [Adapted from12]

This study focuses on 158 falang xiaojie, brothel-based prostitutes working in hair salons, barbershops, and small Karaoke dancing bars. In contrast to higher-level, brothel-based prostitutes who are often hired primarily as social escorts, the falang xiaojie are more likely to provide sexual services and are thus at greater risk for acquiring HIV/AIDS. In addition, this class of FSWs, as well as categories 6 to 7, are likely to serve different levels of migrant (“floating”) population, who are at great risk for HIV6 (see “Discussion”).

Data are presented from fieldwork conducted in 4 red light districts in 2 provinces of China. The majority of information was obtained in 2001 from 3 towns near a southwestern provincial capital, city A. Town 1 is approximately 1 hour by bus from city A and located alongside a main highway. It has a new economic development zone with a red light district that includes 20 brothels. Towns 2 and 3, a little farther from city A, have 23 and 40 brothels, respectively. The sex trade business in these 2 towns is not as good as in town 1, in part because of the distance from the capital, source of most of the clientele, and in part because of their strict anti-prostitution policies. All the brothels in the 3 towns are registered as “singing–dancing bars” or “entertainment cities.” Data from these 3 red light districts near city A are complemented by data collected in 2000 from a village located in the suburbs of a wealthy, coastal city, city B. This is a much more developed area; both the price of sex trade and the per-capita income are twice those of the 3 inland towns. There are 13 brothels in the village of city B and the clients there are businessmen from other provinces and Hong Kong.

Investigations of commercial sex work present a number of challenges that are typical of research on stigmatized populations, which make it difficult to develop representative samples. In this study, city A was identified by the China–U.K. HIV–AIDS Prevention and Care Project; nearby towns were selected by the study team. The red light districts in each town were systematically mapped so that all brothel managers could be approached. Then, ethnographic observation was carried out in the red light districts over a 3-month period, and informal, semistructured interviews with managers, FSWs, and their clients were conducted. A total of 38 brothels and 211 individuals (148 FSWs, 32 clients, 31 others, including managers, pharmacists, and local merchants) in the 3 towns were involved (Table 2). Approximately half of the 83 brothel managers who were approached refused to participate, which meant that their FSWs were also not approached. Even when a manager agreed, however, some FSWs refused to answer questions or participate in conversations.

Employment and Soliciting Types in 4 Red-Light Districts

Fieldwork was conducted by 6 interviewers under the supervision of the Institute for Sexuality and Gender of Peoples University in Beijing (Pan Suiming [Supervisor], Liu Zhengying, Huang Yingying, Wang Jie, Zhang Huixia, Yang Rui, Pan Ying). Additional fieldwork was conducted by one of the authors (Y.H.) in a fourth red light district located in the outskirts of city B. In this case, FSWs were approached initially for interviews, and introduction to the brothel manager was then requested. This strategy resulted in participation by 7 of 13 brothel managers and interviews with 10 prostitutes and clients (Table 2). In each location, interviewers lived in nearby hotels, integrating gradually into the local setting. Observation and interview notes were recorded each evening.

Analysis of the fieldnotes was conducted by pairs of interviewers. Data were initially coded by case and by topics developed through discussions among the interviewers after the fieldwork, including the descriptive categories that measured occupational control. In this article, the organization of female sex work is explored through description of FSWs' relation to brothel managers and to clients. The content of their work is defined by the different practices and control in relation to sex work itself. Lastly, FSWs' knowledge of health risks and degree to which they identify with being a prostitute are assessed as indicators of control over the knowledge they need to increase earning power while still protecting themselves.

This study was reviewed by the Institutional Review Board organized for the China–U.K. HIV–AIDS Prevention and Care Project as a subproject. Gifts or dinner (approximately $10) were provided as compensation for interviews. Participant names used here are fictitious.


The falang xiaojie brothel-based FSWs were young women between 17 and 31 years of age. The median age of FSWs in the 3 towns was 20, and in the suburb of city B, 23. Twenty percent of the FSWs in the 3 towns provided escort but not sexual services. All of the FSWs in the suburb of city B provided sexual services.

Two thirds of the managers were women, aged 24 to 45 years. Managers make the rules, defining schedules, the price of sex trade, payment for the “introduction” fee, and the place of work. In brothel-based prostitution, some practices were routine such as the price and lowest tip. Payment for one-time sex in the towns was approximately $12 and in the suburb of city B, approximately $20 (Median Chinese urban income is approximately $100/month.). Usually, 20% of the payment was given to managers, although in some cases, up to 50% was given. Prices differed across communities but were similar within a community. Managers also provided training in dress, makeup, and appropriate behavior (eg, “seeming naïve, elegant, and educated rather than loud and abrasive”).

No systematic training was offered on sexual skills outside of showing an erotic videotape, and almost no information was provided regarding protection from violence, pregnancy, and STDs. Often managers themselves knew little and were embarrassed to talk about these issues, only discussing prevention of STDs if newcomers turned to them for help.

The Organization of Work

Relationships Between Female Sex Workers and Managers.

For brothel-based prostitution, there are 3 main employment arrangements. The most common combines housing and work because most FSWs are concerned with protecting their identity and do business outside their hometown. Semislave-based arrangements were noted to be a restrictive version of this type, found in the less developed inland areas. Employment-based arrangements that do not include housing are more common in the wealthy coastal areas of China13 (Table 2).

The cost of combining housing with work is relative loss of freedom, because FSWs live under the watchful eye of the manager. They are more likely to obey the rules than advocate for change. In contrast to those in semislave-based arrangements, however, they are free to enter or leave the occupation and are allowed to ask for several days' holiday.

Semislave-based sex work is the most passive arrangement. These young women are usually intimidated into prostitution or recruited from other cities under false pretenses and not allowed to leave. Some brothels even lock FSWs onto the premises after business hours. These FSWs have little power to negotiate with managers or control their situation. Violation of rules usually results in punishment, including a beating.

At the other end of the spectrum, employment-based FSWs are able to choose their managers and play an active role in constructing the rules of sex trade. For example, some employment-based FSWs complained about their managers' failure to solicit clients and actively pushed the managers to get more business. This greater autonomy vis-à-vis the manager seemed to be related to a more open attitude toward prostitution in general and greater power in negotiation with clients.

Solicitation of Clients.

Although soliciting clients can take many forms, there were 3 general categories: solicitation initiated by the manager, by the FSW, and by the client (Table 2). Manager-initiated solicitation is the most common in employment-based brothels, as well as those where FSWs live and work. This involves bringing a client to the brothel, offering an FSW or perhaps several FSWs, and allowing the client to select 1. Manager-initiated solicitation is regarded as the most professional because FSWs believe this is the manager's responsibility. Soliciting on the streets is viewed as both shameful and putting FSWs at increased risk of arrest. Prostitute-initiated solicitation is most common in semislave-based brothels where managers force the FSWs onto the streets. Client-initiated solicitation is typical for those clients who are very familiar with the sex industry and exercise control over encounters initiated by managers or FSWs. The key criterion is who is most active in initiating the trade.

FSWs have different behaviors toward clients after being solicited. Some abide by the philosophy “every client is the same and will be welcomed” (lai zhe shi ke). For them, clients mean nothing but business and money. However, some are more selective, based on a client's appearance or home city; for example, some prostitutes in city B prefer clients from Hong Kong and Taiwan. They believe that clients who look well-educated will be gentle and clean, which will reduce the risk of violence and STDs. When FSWs want to reject a client, they adopt such strategies as giving the excuse that “my elder aunt is coming” (meaning menstruation) or turning their back to clients so that they would ask the manager to refer another prostitute. Thus, autonomy and power in relation to clients is expressed not only through the initial solicitation, but also as the FSWs negotiate whether to continue the trade. Furthermore, even those with little autonomy are sometimes able to exercise indirect influence over the negotiations.

The Content of Work

Control Over Condom Use and Sexual Activities.

All the FSWs interviewed indicated that they are happy or even grateful if clients use a condom, and those who discussed sexual activities indicated that their preferred sexual activity is vaginal intercourse. Oral sex (usually female to male), anal sex, and having sex with 2 or 3 prostitutes at 1 time are favored by some clients but unacceptable to many FSWs. In the inland 3 towns, no more than one third of FSWs would perform oral sex and almost none would engage in anal sex; just 1 or 2 FSWs in 1 red light district were reported to offer this service. When the client refuses to use a condom, or the sexual activity proposed or the client proposing it is not attractive, or is unclean or threatening, FSWs face a choice between money, their own sexual preferences, and possible risks of pregnancy, STDs, and HIV.

In the towns, less than 10% of FSWs firmly stated that they refuse to have sex with clients not wearing a condom; some try their best to persuade clients to use 1, saying such things as, “You have a family and should be responsible to your wife.” However, the majority (70–80%) indicated that they would accept a client without condom use if they “observed” that the clients were “clean” with no symptoms of STDs. In the wealthy suburb of city B, however, FSWs appeared to be much more assertive about condom use, and when a manager was asked about STDs, she simply replied that FSWs use condoms. For all FSWs, even those in city B, condom negotiations are especially difficult with regular clients, as well as for FSWs' first sexual experience. When sexual preferences are the issue, more FSWs indicated they would refuse the money. For example, clients who request oral sex are often rejected by FSWs who think it is unclean; prostitutes who offer such services to clients are scorned by their coworkers.

Despite failure to negotiate condom use, FSWs do pay attention to STDs and are afraid of their impact on business. They worry that clients would reject them and managers would complain or lay them off. FSWs engage in some preventive activities, including observing the penis, showering and douching after sex. If clients “look” safe and clean, FSWs will likely accept them even without condom use. If they experience symptoms, most FSWs go to a clinic, available in a red light district but often quite expensive, or to a local hospital. We found only a few FSWs afraid of acquiring HIV, and among all those interviewed, only one FSW reported seeking knowledge about STDs and contraception before entering the sex industry. Recent studies have shown that the great majority think HIV is still far away from their lives.14

Economic circumstances greatly influence these negotiations. Based on our observations, the prevalence of condom use and the autonomy of prostitutes are much higher in wealthier, economically developed areas. In our study, this included town 1 and city B. The managers and prostitutes themselves are aware of these phenomena: “Nowadays, the economic situation is worse; there are more xiaojie (prostitutes) and fewer clients. In the mid-1990s, there were lots of clients and we could select them, but now it's hard to do business.” In poorer areas, the oversupply of FSWs is likely to decrease their bargaining power vis-à-vis both clients and managers. Overall, money has become a stronger consideration for FSWs weighing risks and benefits from the sex trade in recent years. Under these circumstances, cooperation between FSWs, sharing knowledge and skills regarding negotiations with clients, and protection from pregnancy, STDs, and violence is less likely.

Control Over Knowledge and Skills.

Developing a repertoire of skills in sexual practices and in negotiating with managers and clients would increase FSWs' control over their occupation. A few FSWs do actively seek knowledge about sexual practices, through reading or watching videos, or undertaking activities to enhance their business opportunities such as cooking meals for bosses or clients, or purchasing a cell phone to increase their accessibility, with the goal of widening their social networks and hopefully climbing up to the highest class of prostitution: to be second wife. One FSW from town 1 stated that a prostitute should “use her brain not only her body,” describing different strategies to please clients so they will offer higher tips. Most FSWs, however, are passive and make no effort to develop knowledge or skills. One reason for this may be the shame associated with their occupation.

Identification With the Occupation.

Although prostitution has enjoyed a long and complex history in China, it is illegal and highly stigmatized. Popular culture portrays prostitutes either as poor girls who are forced into prostitution or as women who sell their souls for “dirty money.” In addition to the direct influence over prostitutes' identity and practice, these social attitudes toward the sex trade and sexuality also influence policymakers, managers, and other people (eg, doctors, condom sellers) who live or work in their communities and directly or indirectly affect the work lives of FSWs.

Although these popular attitudes might predict that FSWs hide or deny their activities, the data we collected indicate a range of attitudes, from shame and denial (eg, “this is not a place for human being,” “I never imagined I would be here,” “the thing I'm most afraid of is that my relatives know I'm here”) to accepting prostitution as a lifestyle (eg, “selling sex is not the point, but selling the soul is shameful,” “nowadays, it is poverty that would be looked down on rather than prostitution.”). These latter views are more common in town 1 and the suburb of city B. Overall, however, the most common attitude is ambivalence, as illustrated by these excerpts from fieldnotes:

Xiao Bai regards prostitution as an experience of life and her own choice, but warns herself not to be “too erotic” (that is, providing different kinds of sexual behaviors besides traditional intercourse). “Sometimes I feel sick about doing it (selling sex).”

Xiao Zhuang regards prostitution as a low-status job, but she compares her occupation favorably with others: “We are much better than those (businessmen) who cheat for money.”

Almost all FSWs interviewed offered statements to justify entering prostitution. These included poverty, acquiring resources for their future, and gender equality. Some justifications emphasize their autonomy, which may mean they are trying to find the advantages of the occupation. However, some believe that being a prostitute is their fate and they have no ability to choose; others state that they are intimated and forced into prostitution, which means they have no autonomy and control over their entering or leaving prostitution.


Prostitution has been a visible part of Chinese culture throughout history,10 but the devastating health consequences of commercial sex were not documented until the 20th century. Epidemiologic studies revealed that in the 1940s preliberation period, STDs were the third most common hospital-based diseases.11 A substantial number of people living in urban coastal cities had untreated syphilis, which reached prevalence of 40% to 50% in some national minorities.11 Although prostitution and STDs were reported to be eradicated, since the end of the Maoist era, China's commercial sex industry has reemerged.9,10,12,13,15,16

Depending on the definition used, estimates of the number of sex workers vary from less than half a million17 to as many as 3 to 4 million, or 0.03% to 0.1% of the population.1,3 According to a recent nationwide population-based probability survey in 2000,17 6.4% of men 20 to 64 years old have engaged in commercial sex at least once during their lives. STDs have also returned to China,18,19 mostly in response to changing social attitudes and economic freedom. Not surprisingly, STDS are particularly common in FSWs.7,8 Surveillance in 2000 among prostitutes in Guangxi and Yunnan provinces reported HIV prevalence as 10.7% and 4.6%, respectively.3 HIV prevalence in a reeducation center in Fujian province was found to be more than 2%.8

The current study was undertaken to provide a framework for HIV prevention activities in commercial sex workers in China. The work that prostitutes perform and in what locations20,21 are neglected subjects. We examined 7 classes of sex workers and chose to focus on the lowest class of brothel workers (falang xiaojie) because this population is most accessible to study and intervention and is likely quite important in the spread of disease.

The results reveal a complex and heterogenous relationship between the sex worker and brothel manager that helps to define occupational behavior. Power and autonomy in any occupation can be measured by control over how the work is organized. These “terms of work”22 include setting standards and practices, negotiating working hours, wage and benefit packages, and workplace safety. Power and autonomy also derive from control over the “content of work,” the methods and practices of work activities.23 Professionals seek control in relation to clients primarily by developing exclusive expertise, which allows them access to autonomy, authority, and status.24 This corresponds to an additional component of occupational control, “… the degree to which members of an occupational look to the occupation rather than to the employing organization for support and their knowledge base.”23

Prostitutes in China generally lack collective consciousness and occupational control. This limitation is unlikely to change because prostitution is illegal throughout China. Enforcement is a constant threat, particularly in the fall of the year, when police sweeps are carried out and many prostitutes are arrested, fined, or put into reeducation centers.14 However, because prostitution also contributes to local economies, enforcement is temporary and variable, generally directed at sex workers with the fewest resources.

Given these conditions, it is difficult for sex workers to control their clientele or to protect their health, and they cannot depend on their employer or the government for help. Recent studies have shown that sex workers have little knowledge of HIV/AIDS.25,26 In one study of 701 prostitutes from a Shenzhen reeducation center,14 10% had never heard of AIDS, 21.7% felt that AIDS is a disease confined to the homosexual population, and approximately 35% of the respondents believed that AIDS is a curable disease. Although 37% believed that condoms are effective in preventing HIV/AIDS, 91.7% thought they had low chances of contracting HIV. In another study, approximately half of the FSWs believed that only foreigners can acquire HIV.26

Accurate information is critical to prevent STDs. However, our results demonstrate that the selection of clients and the sexual behaviors engaged are not always under the control of the sex worker. Perhaps most important, condom use by Chinese sex workers is irregular, ranging from 15% to 30%.27 According to a national survey of sexual behavior,17 46.9% of males reported used condom regularly during sexual encounters with FSWs. A survey of 6457 FSWs in 23 provinces in 199528 indicated that only one third had ever used condoms and 13% used them regularly. In the Shenzhen study,14 condom use rates were reported to be higher, which is consistent with our data from the wealthy suburbs of city B.

FSWs typically use visual assessment to determine whether clients have an STD and thus need to use a condom.14 This study and others have found that FSWs' lack of condom use is largely the result of clients' preferences.14,27 Two studies demonstrated that repeated educational interventions significantly increased condom use.26,29 Notably, in Thailand, the promotion of “condom-only brothels” has been credited with increased condom use in some regions.30

A number of factors influence the risks of STDs/HIV in prostitutes. National and local policies set the stage. Local economic conditions determine the supply and demand for sex work. Our study demonstrates that the organization of sex work, control by FSWs over the content of that work, and their relative autonomy in applying skills and knowledge in negotiating with clients vary according to local economic conditions. Furthermore, we found that the roles of brothel managers, FSWs, and clients, and attitudes of FSWs toward their occupation vary under different types of work organization. Reducing the risks for commercial sex workers will require concomitant consideration of all of these factors.

Specifically, the need for better health education is apparent, and such activities will only emerge with national and local support. To protect themselves, commercial sex workers must gain greater power over selection of clients and sexual behavior, including use of condoms. Our results suggest that negotiations are not individual decisions but occur in the context of manager–client–FSW networks, and that when brothel managers exercise control over employees, they must be a focus of education activities as well. In addition, too little attention has been paid to the clients. These include wealthy businessmen, found to be most likely to visit FSWs in a recent national survey17; soldiers, who have been shown to have high STD and HIV rates in other countries31; migrant workers,32 with documented high STD rates6 but unknown HIV incidence and prevalence rates; and, potentially, the “surplus” men produced by China's 1-child family planning policy who may find no sexual outlet over the course of their lives other than commercial sex.33,34 Current prevention programs have not developed an effective approach to educate and train clients, who are often the dominant factor in relationships with FSWs and the main bridge population transmitting STDs and HIV.

It is widely believed that the future of the HIV epidemic depends to a great extent on what transpires in China over the next 10 years. FSWs and their clients are likely to play a central role in the spread of STDs, including HIV. Constructive policies to prevent disease in FSWs must be based on openly addressing both the existence of this occupation and its heterogeneity.


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