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Colleague's E-mail is Invalid. Your message has been successfully sent to your colleague. Save my selection. We thank Dr. Pierre Fournier, Dr. Slim Haddad, and Caroline Tourigny for their encouragement and useful comments in writing this article. We also thank Dr. Vinh-Kim Nguyen for his editing and insight.
E-mail: [ protected] om. By using the example of FSWs in China, we intend to demonstrate the role that structural factors can have on HIV transmission above and beyond individual high-risk behaviors. Analysis of the literature suggests that major determinants of HIV transmission amongst FSWs in China include sociopolitical context, gender, work environment and finally, risky sexual behaviors. Chinese FSWs live in a specific sociopolitical context that shapes their capacities to engage in safe-sex practices.
The literature suggests that Chinese female sex workers live in a specific sociopolitical and cultural context that shapes their capacities to engage in safe-sex practices. In response, this review seeks to underscore the importance of structural factors in the context of a strong state, such as China. These figures underestimate actual values as current surveillance capacities are insufficient.
In analyzing the epidemic, many authors have pointed to the growing s of sex workers in China and their potential to generalize the epidemic. The common opinion is that female sex workers FSWs may serve as vectors of the disease to an otherwise spared general population. Despite calls for systematic studies of context and group-specific risk factors, 7,20 few, if any, articles attempt to look beyond risky behaviors and sexual knowledge but see Ref.
Automated and manual methods were used for assessing the relevant medical and social literature. Grey literature was also obtained from government and multilateral organizations' publications. The manual method included examining the reference sections of reviewed articles as well as the handsearching of 7 relevant journals to identify additional articles. The of this review are presented in a manner that illuminates factors—from the macro- to the microlevel—that condition risk in Chinese FSWs Fig. We have chosen to highlight state laws and policy, migration, gender, and work organization, as we feel that such factors are particularly relevant to FSWs and underscore the importance of macro- and mesolevel structural factors in creating a high risk environment.
We also review better-documented microlevel factors such as the demographic profile of FSWs and risk behaviors. In , China proclaimed the abolition of prostitution as one of the greatest achievements of the new leadership. Additionally, by , China managed to eradicate nearly all sexually transmitted infections STIs.
In , a US State department report on China estimated the of sex workers to be around 10 million. The Chinese government's initial response to the emerging HIV epidemic during the late s was to ban all foreigners with HIV from entering China 29 or if already in China, preventing them from crossing between provinces.
Because prostitution is illegal in China, FSWs are subject to administrative and criminal sanctions. This statute requires local governments to provide confidential HIV testing and antiretroviral drugs to residents and outlaws discrimination against HIV-positive individuals while guaranteeing them a right to healthcare, employment, marriage, and education. Under this new statute, the state requires that all HIV tests be given at no cost and bars officials from disclosing the names or personal information of those who test positive.
However, those seen as intentionally transmitting the virus to others will be punished by civil and criminal means. For the moment, it is unclear as to how this statute applies to highly marginalized populations such as sex workers and migrants. Finally, it should be recognized that although this statute is fairly progressive, it may take some time for the harms of the measures to be eliminated.
As Table 1 demonstrates, many FSWs are members of China's floating population—a largely rural-to-urban migrant population that is technically illegal under China's hukou system household registration system. Migrants in China are thus a subpopulation of special importance for the transmission of HIV 38 ; and the conditions behind, and the process of, migration facilitates risky sexual decisions such as engaging in commercial sex. Further, it demonstrates that a myopic focus on sexual behavior misses social and economic factors that conditioned the behavior in the first place.
The economic successes achieved in the Post-Mao era have had huge implications for gender relations and gender equality. The emergence of open markets, foreign exchange, and increases in disposable income created new socioeconomic opportunities. However, it also reintroduced gender subordination and oppression in the work force discrimination, sexual harassment, etc. This alteration in women's social status and security is epitomized by the return of FSWs to China. The concept of vulnerability stems from women's, and thus FSWs', greater probability of acquiring HIV infection when compared with men.
Chinese FSWs, as well as Chinese women, are subjected to biologic, cultural, demographic, economic, judicial, and political influences that amplify HIV exposure and transmission by conditioning a high-risk environment. Because of occupational discrimination, Chinese women are likely to earn less than men or to be the first to be laid off by downsizing state-owned enterprises. To survive, or to supplement their incomes, many women have turned to sex work. With the rapid expansion of privately owned or run business, workplace gender dynamics have changed, often subjecting women to sexual harassment, sexual assault, rape, or forced prostitution.
Although stigmatization may place FSWs at increased risk, it is important to note that the stigmatization is rooted in society-wide views on gender and in state law and policy. According to Huang et al. Other include streetwalkers, factory girls, courtesans, and second wives. The type of work organization—the economic and social relationship between the FSW and manager—may largely determine FSWs' motivations to enter and remain in the sex industry. There are 3 common employment arrangements Table 2.
However, women living under this arrangement have the freedom to come and go as they please, as well as ask for days off. They turn all their earnings over to the manager who provides them with daily necessities in return.
These women have usually been intimidated into prostitution or recruited from other cities under false pretences. Gatekeepers are defined as persons who manage sex workers; these include mommies, pimps, establishment owners, managers, and other employees. Despite the importance of gatekeepers' opinions concerning condom use and STIs, many have negative attitudes toward both, as they fear that forcing clients to use condoms will negatively affect business and that STI education will cause girls to quit.
However, in poorer areas, the oversupply of FSWs may decrease bargaining power with gatekeepers and clients, no matter what the type of work organization. Post-Mao policies have encouraged son preference through the decollectivization of agriculture, the 1-child family planning policy, and the diffusion of ultrasound technology that allows for sex-selective abortion. The result is an estimated 8.
They may not be able to afford rising bride prices and will resort to sex workers for sexual services, as the immediate costs of paying a sex worker are less than the long-term investments necessary to find a bride. Of the miners who actively sought FSWs, This is similar to the findings of another study conducted in the cities Beijing, Shanghai, and Nanjing, where only Similarly, the presence of a regular sex partner in an FSW's life may also be a risk factor for the transmission of HIV, as these partners may have multiple partners, thus enlarging sexual networks.
Consequently, there is a vital need for research on the regular partners of FSWs in China. The literature shows that FSWs associate physical appearance with health status. The use of condoms by FSWs seemed to vary depending on work organization, 3 income, 2,3,10 and gatekeeper support. In addition to the day-to-day sexual services provided in Chinese context by FSWs, some clients purchase a longer period of sexual service from a woman.
This relationship, however, does not prevent many FSWs from providing services to other clients. By labeling FSWs as the vector of the epidemic, they become further stigmatized and marginalized. Such structural factors run throughout communities creating an environment conducive to high-risk behaviors amongst the most vulnerable segments of society. At the macro level, there is little literature discussing the role of Chinese policy and law on at-risk populations such as sex workers.
Given the strong role of the Chinese state, such research is necessary and timely. Further, the contribution of other phenomena at the macro- and mesolevels, such as the greater proportion of males in China, migration, work organization, gate keepers, clients, and stable boyfriends need to be identified if we are to effectively understand and further implement strategies for the prevention of HIV proliferation in China. For instance, China's public health programs often ignore the massive problem of undocumented migrants who have limited, if any, access to health care 7 and of whom, a ificant are FSWs and their clients.
Some error has occurred while processing your request. Please try after some time. Received for publication October 4, , and accepted February 2, Abstract In Brief. Goal: By using the example of FSWs in China, we intend to demonstrate the role that structural factors can have on HIV transmission above and beyond individual high-risk behaviors.
Study De: Literature review of years — : Analysis of the literature suggests that major determinants of HIV transmission amongst FSWs in China include sociopolitical context, gender, work environment and finally, risky sexual behaviors. Conclusions: Chinese FSWs live in a specific sociopolitical context that shapes their capacities to engage in safe-sex practices. The examples given in both this diagram and the review are specifically pertinent to FSWs; however, they should not be mistaken as being comprehensive of all possible determinants of risk.
HIV infection and sexually transmitted diseases in female commercial sex workers in China. J Acquir Immune Defic Syndr ; — HIV knowledge and risk behaviour of female sex workers in Yunnan Province, China: potential as bridging groups to the general population. AIDS Care ; — Sex Transm Dis ; — Behavioral surveillance and factors associated with condom use and STD incidences among the male commercial sex client population in Hong Kong— of two surveys.
Needle sharing and sex-related risk behaviours among drug users in Shenzhen, a city in Guangdong, southern China.Sex on the China women
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Sex with Women Among Men Who Have Sex with Men in China: Prevalence and Sexual Practices