Introduction

Although commercial sex is illegal in China, there are many female sex workers who work at legitimately licensed entertainment venues, including karaoke bars, saunas, night clubs, discos, or massage parlors, engaging in unprotected commercial sex with business patrons (Li et al., 2006; Wei et al., 2004). These practices put both the sex workers and their clients at high risk of acquiring or transmitting sexually transmitted diseases (STDs) and HIV (Ding et al., 2005; Xia & Yang, 2005; Yang, Li, Stanton, Chen, & Liu, 2005a; Yang et al., 2005b). Studies have reported that the STD and HIV infection rates among sex workers in China are high. For example, among sex workers in re-education centers in Sichuan, 48.8% of inmates had an STD (Galvin & Cohen, 2004). A study in Henan reported that 20% of sex workers in a community sample had STD history (Ding et al.).

The clients of female entertainment workers also represented a high-risk population for HIV infection and transmission (Basuki et al., 2002). While many studies have focused on infection rates and the behavior of female sex workers in entertainment venues, relatively less is known about their clients’ perceptions, beliefs, and behavior as potential disease transmission populations. As documented in studies in other countries, sex workers’ clients played important roles in their unprotected sexual behaviors. Client refusal was cited as the major reason for not using condoms in several studies (Huang, Henderson, Pan, & Cohen, 2004; Wong & Yilin, 2003).

Our previous study with a large cross-sectional sample of 4,510 market vendors demonstrated the sexual risk among entertainment venue visitors. We found that male participants who reported visiting entertainment venues were more than five times more likely to report unprotected sex than those who did not. Entertainment venue visits were also significantly correlated with STD infection (Li et al., 2008). HIV prevention in entertainment venues in China needs to go beyond targeting female entertainment workers.

This study was a formative research guided by the following questions: What kind of entertainment venue does commercial sex take place in? How do the entertainment venue clients perceive commercial sex and their STD/HIV risk? And how do they protect themselves from STDs/HIV? We used qualitative data from in-depth interviews of entertainment venue visitors to explore their individual characteristics, sexual behavior and risk, and their attitude toward commercial sex.

Methods

Study Background and Participants

This study was part of a National Institute of Mental Health (NIMH) Collaborative HIV/STD Prevention Trial conducted in five countries (NIMH Collaborative HIV/STD Prevention Trial Group, 2007). The sub-study reported here was conducted among market vendors in Fuzhou—a large eastern city in China. The market vendors were chosen as the focal population; this was a relatively affluent group to engage in commercial sexual behavior (Detels et al., 2003). Six local food markets were randomly selected from 40 local food markets. Flyers were posted in the selected market to advertise the study. Study staff approached potential study participants in the market and screened for their eligibility (aged 18–49 years, self-reported visiting an entertainment venue at least once in the last 3 months). The refusal rate was less than 5%. The study was approved by the University of California, Los Angeles, and Chinese Center for Disease Control and Prevention Institutional Review Boards. Informed consent was obtained from participants prior to the interview.

A total of 30 market vendors who visited entertainment venues in the past 3 months participated in the study. Most of them were between 30 and 50 years of age, married and living with a spouse, grew up in the local area, had a junior high or lower education, and earned less than 5,000 Yuan (US $715.00) per month (Table 1).

Data Collection

The in-depth interviews lasted from 60 to 120 minutes and were conducted in a private room by trained interviewers. Interviews were semi-structured following specific guidelines and included a set of open-ended probes. Participants were asked about their background information, perceived risk of potential sexual contacts in entertainment venues, perceived cultural acceptance of commercial sex, and approaches to prevent STDs/HIV infection. All interviews were digitally audio-recorded with no personal identifiers collected. Participants received 20 Yuan (US $3.00) upon completion of the interview.

Data Analysis

The digitally recorded interviews were transcribed verbatim and imported to ATLAS.ti version 5. (Muhr, 2004) for coding and analysis. A first draft of the code system was developed based on the interview guidelines and emergent content of several interview transcripts. To establish acceptable levels of inter-coder reliability, each coder independently coded a set of transcripts and then compared each other’s coding for consistency. Clarifications were made by discussing the difference among the analysts until each code was independently applied with 80% or more of agreement (Sandelowski, 1986). Following a variety of revisions, a final code system was established with four main themes. Analyses were conducted by identifying the themes occurring most frequently. All transcriptions, coding, and analyses were completed in Chinese, and the final results were translated to English using the “forward-backward” translation procedure (Brislin, 1970).

Results

Examining the interview transcripts through the code and text search, four central themes relevant to the study objectives were identified: (1) commercial sex in entertainment venues, (2) attitudes toward commercial sex, (3) STD/HIV education and perceived risk, and (4) STD/HIV prevention. Results for each of these themes are as follows.

Commercial Sex in entertainment Venues

Participants reported saunas (80%), karaoke bars (50%), and massage centers (37%) as the most frequently visited venues in the past 3 months. Frequencies of visiting varied from once every 3 months to once per week. All 30 participants in our study were aware of the commercial sex in these entertainment venues. Seventy-three percent of the study participants reported having commercial sex when they visited these venues—50% of the full sample reported purchasing commercial sex in saunas, 37% in hair salon/massage centers, and 27% in karaoke bars. Commercial sex activity was known to take place in private sections inside the entertainment venues, the entertainment workers’ rental apartments, or hotel rooms. A “whole set” service including bathing, massage, oral sex, masturbation, breast sex, and vaginal sex usually cost about 200–400 Yuan (US $30.00 to $60.00)— roughly 10% of the average monthly income for study participants.

As to the preference of entertainment venues, we found that high-class night clubs were often too expensive for the market vendors, so few of our respondents reported seeking commercial sex in such venues. Market people most preferred saunas and massage centers because they were less likely to catch the attention of police and therefore were considered “safer” than the hair salon and street-based sex workers. Particularly, the sex services in saunas were perceived to be of “higher quality” than the service in massage centers. The street-based sex workers, although less expensive, were the least preferred by the respondents because they were “promiscuous” and “dirty.”

There are private rooms and TVs in saunas and massage centers, but in hair salons, you don’t even have a place to take a shower . . . The girls in hair salons are old, married ones and unattractive. (Age 36, married, junior high education)

Saunas are safer than hair salons, because they have private sections for sex, and you are less likely to catch the attention of police .. . Want to know why? Because saunas usually hand out free membership cards to the police officers; they have the protection .. . (Age 45, divorced, elementary school education)

The sex workers in saunas are cleaner, and if you don’t use a condom, they will never do it with you. This is not like the street-based ones, who are willing to do it without condoms, so it is easy to catch gonorrhea and syphilis. (Age 39, married, junior high education)

Attitudes Toward Commercial Sex

The study participants, whether engaged in commercial sex or not, all held very open and liberal attitudes toward commercial sex. None of the participants perceived purchasing commercial sex as disgraceful. Commercial sex was perceived as a social norm and part of males’ nature. Several participants believed that commercial sex services were beneficial to the society, because they play an active role in reducing the occurrence of sexual offenses.

As a metaphor, you have been eating a certain kind of food for a long time, and you become sick of it; you want to try something new, don’t you? It is human nature. . . It is also a symbol of high social-economic status, because only rich men could afford it. (Age 49, married, elemen¬tary school education)

Of course, it is so normal these days, anybody could do it as long as you have money . . . If a friend invited you to do it together, and you refused, it is kind of losing face. (Age 32, married, senior high education)

Extramarital sex was believed to be of better quality because it could provide “excitement” and “fresh feeling.” Reports also show that the use of alcohol in entertainment venues frequently preceded commercial sex activity. One participant described commercial sex as an “addictive” behavior.

My wife can’t satisfy me; I don’t have much feeling about her. I just want to try out the new ones. You know, wild flowers always look prettier than the ones at home. (Age 35, married, junior high education)

After you are half-drunk, all the whores will be attractive to you. (Age 45, divorced, elementary school education)

It is like using drugs. At the beginning you just want to try, then you want a second time, a third time .. . (Age 37, married, elementary school education)

Those who didn’t admit to having engaged in commercial sex also considered it acceptable. The reasons reported for not having been involved in commercial sex included not having enough money or energy. Some expressed willingness and interest to do it if they had enough money or time. Only two participants cited responsibility for family and fear of STDs/HIV as the reason for not purchasing commercial sex. Many participants (67%) held a sympathetic attitude toward sex workers. They regarded commercial sex as a normal “profession” in the society. Not surprisingly, these sympathetic attitudes were expressed by those people who admitted engaging in commercial sex themselves— perhaps a rationalization for their behavior.

I chat with the girls sometimes, and they like me. I don’t look down upon them because they are forced to do the job. Some were beguiled by people, and some are doing it to support their whole family. (Age 40, married, junior high education)

I think most of the people will accept commercial sex these days. We need it physically and psychologically. There is the market because there is the demand. (Age 32, married, senior high education)

STD/HIV Education and Perceived Risk

Participants reported getting STD/HIV information from TV, newspapers, radio broadcasts, posters, and service providers. They also described how health information was shared among market vendors when visiting entertainment venues. Participants’ family members, especially spouses, also warned them not to engage in commercial sex to prevent STDs and HIV infection. A few participants also reported receiving STD/HIV education from sex workers.

Yes, my friend once got an STD. He said he got pus all over the underwear, and he couldn’t pee. Then he used some foreign imported medicine and got it cured. He has told me not to do this anymore. (Age 45, married, elementary school education)

The girls I had sex with taught me what STDs are and how to prevent them. She insisted to use condoms. You know, those prostitutes are rich; they value their health too. (Age 45, junior high education)

Most participants acknowledged that commercial sex will likely increase the risk of STDs/HIV infection. Yet, some still believed in taking chances, hoping that having commercial sex occasionally would not result in disease infection. The perceived risks of STDs/HIV infection did not deter the participants from engaging in commercial sex.

I go there only occasionally, so I will be alright. Only those who go there every day and sleep with a lot of women will get the disease, right? (Age 37, married, elemen¬tary school education)

I know there is a risk, but when you are there, you will be careless, you will be like, ‘Let’s enjoy it first. Who cares about tomorrow?’ .. . Sometimes, you do it even when you knew that she has infection. (Age 49, married, junior high education)

We know the disease, but we still do what we’d like to do .. . (Age 45, married, ele¬mentary school education)

Ten percent of the participants reported a history of STD symptoms, and 23% of the others were aware of their friends having had STD symptoms. A large proportion of participants believed that they were safe because they used condoms with sex workers. Condoms were believed to be 100% effective in preventing STDs/HIV transmission. Moreover, we found a prevailing misunderstanding that symptom free means no disease is present.

I am all fine now. If I had an STD, I would feel pain when peeing and some other syndromes, but I don’t. So I am pretty sure that I don’t have an STD. (Age 38, married, senior high education)

(Interviewer: Do you know how to prevent STDs?) That depends on your health status. If you are strong enough, you won’t get the disease. I am strong, and I have very good health habits. I take a shower to clean myself up every time before and after sex, so I am sure I am safe. (Age 49, married, elementary school education.

STD/HIV Prevention

All our study participants knew that condoms are easily accessible in supermarkets, pharmacies, and vending machines. Moreover, entertainment venue-based sex workers normally have condoms prepared in their work places. The majority of the participants reported that they consistently used condoms with sex workers. They reported that the sex workers in entertainment venues insisted on using condoms for every sex act—otherwise, they would not do it. Street-based sex workers, on the other hand, were reported to not make regular use of condoms.

The girl will tell you, ‘You have to use a condom, it is safe for both of us, and the feeling is the same.’ (Age 49, married, elementary school education)

If you don’t use a condom, they won’t do it. Even you pull it out in the middle, they will still ask you to put it back on. (Age 45, married, junior high education)

There were still some participants who did not consistently use condoms with sex workers. The reasons cited for not using condoms include: being troublesome, reduced comfort level, and insufficient understanding about STDs/HIV transmission. Some of the participants did not know how to use condoms correctly.

(Interviewer: When do you start using a condom?) In the middle of the sex. (Interviewer: Do you know exactly how to use it?) I have no idea, I haven’t used it before. (Age 38, married, junior high education)

I used it occasionally, when I suspect the one has an STD; otherwise, I don’t use it. (Interviewer: How do you know if someone has an STD or not?) Well, I take a guess. (Age 37, married, elementary school edu¬cation)

Few participants used condoms with regular sex partners or spouses because STDs/HIV infection was considered only associated with unfamiliar sex workers. Reports indicate the belief that it is safe to have sex with stable partners and sex workers they have known for a while. Condoms were only used among couples for the purpose of preventing pregnancy instead of STDs/HIV infection. The inconstant and incorrect use of condoms clearly indicates the high risks for these individuals becoming infected with STDs/HIV.

(Interviewer: Did you use a condom with that karaoke girl who you are familiar with?) No, because there is real love between us. I know she only does it with a limited number of people at work. (Age 45, married, elementary school education)

I used condoms with my wife, because our kid was still young at that time. We were afraid to get pregnant again. Now we don’t use it anymore because the kid has grown up. (Age 39, married, junior high education)

Beyond condom use, study participants reported a reliance on improper practices to prevent STD/HIV infection, such as washing or douching. Further, some participants said that they can identify infected sex workers by observation. And another faulty belief was that good health protected one from becoming infected with STDs/HIV.

I always ask the girls if they are clean, but they will always say yes. Anyway, I still ask them to take a shower. If there is no place to take a shower, I will ask them to wipe “there” with a hot towel.. . After you are done, you better wash it with soap and urinate, and the disease can be prevented. And we can judge by looking; for example, if you see white there, you better keep away from her. (Age 49, married, elemen¬tary school education)

My physician has told me earlier, if you see black dots or a red rash down there, it means it is not safe. (Age 49, married, junior high education)

It depends on your health situation. If you are strong enough, you won’t get an STD. If you are weak, of course the bacteria will come to you. (Age 49, married, elementary school education)

Discussion

Different from previous years, sexual transmission is now reported to be the main cause for the spread of HIV (State Council AIDS Working Committee Office, UN Theme Group on AIDS in China, 2007). It is important to examine the contemporary STD/HIV risk factors among high-risk groups who are involved in commercial sex to implement more informed recommen-dations for future intervention and prevention efforts.

Although there have been studies examining the profiles of female sex workers in entertainment venues in China, to date, there have been few, if any, systematic investigations of their clients. This study contributes to a growing literature that used a qualitative method to examine the behavior and attitudes of sex-worker patrons. Findings illustrate the high-risk behaviors that exist in entertainment venues from the clients’ perspective. A large proportion of male entertainment venue visitors engaged in commercial sex, and they seldom use condoms with their spouse and/or regular partners. These individuals are potentially a substantial “bridge” to the general population in spreading STDs/HIV from high-risk groups. As such, this sub-population should be a prime target for intervention efforts.

In this study, we found that although commercial sex is forbidden by law and subject to harsh punishment (Xia & Yang, 2005), it is considered an acceptable behavior. Commercial sex behavior is not only associated with faulty knowledge and weak assessments of risk but with people’s open attitudes toward these activities. Even those study participants who reported not engaging in commercial sex acknowledged that they might under the right circumstances. Until the late 1970s, Chinese people held relatively conservative opinions toward sex (Sommer, 2000). Since the Open Door policies and economic reforms of the past three decades, and the influences of industrialization and exposure to Western culture, attitudes toward sexuality in China have changed to be more open. Premarital and extramarital sex is becoming widely accepted among people in China. The quality of an individual’s sex life is currently more valued than it used to be (Zhang, Li, Li, & Beck, 1999). The changing attitudes toward sex partially explain our findings and explain why heterosexual transmission is becoming the most prominent route of HIV transmission in China. Unless addressed directly, this unregulated “open” attitude toward sex will likely continue to fuel the epidemic of HIV and STDs in the country.

Many studies focused on female sex work¬ers have suggested that high-risk behaviors in commercial sex were not under the control of sex workers who had limited power in condom-use negotiation, while the male clients normally play an influential decision-making role in the sex behavior (Huang et al., 2004; Yang et al., 2005c). Our study has demonstrated that despite the sex workers’ insistence, some clients were still reluctant to use condoms or did not know how to use a condom correctly. This finding highlights the importance of future intervention to address HIV/STD-related risks among sex workers’ clients. Health education targeting commercial-sex clients needs continued focus on condom education, with specific attention to educating clients about the values of consistent condom use with both sex workers and regular sexual partners.

Because clients of commercial sex are normally a “hidden” population, interventions targeting these individuals can be difficult to implement. An important finding from this study was that some clients gained STD/HIV prevention knowledge from the sex workers. This finding is supported by Sanders (2006), who argued that female sex workers could effectively deliver sexual health education to their clients based on their informal role and the information exchange that already took place. The female sex workers’ interactions with male clients can be a mechanism expanded into health education and active disease prevention. The narratives relating to providing health information to clients through their commercial sexual relationships could be formalized into a sexual health education strategy. We suggest that, besides health education among female sex workers on HIV knowledge, communication training to strengthen their skills to negotiate condom use with reluctant clients is also essential. In doing so, sex workers can gain more control over the choice to ensure consistent and proper condom use and prevent sexually transmitted diseases including HIV from spreading.

There are some limitations to our research. The study was conducted in an East-coast city in China, with relatively liberal culture toward commercial sex. The findings may be different from those in other parts of the country. Also, the study participants were food market workers, and the sample is not representative of all clients of female sex workers, limiting the generalizability of the results. Despite the disparities, the results of this study have implications for the development of effective prevention programs among sex workers and their clients in the control of the sexual transmission of STDs/HIV.

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