Female Sex Workers and Their Gatekeepers in China

Study Site

The data were collected in B City of the Guangxi Zhuang Autonomous Region (Guangxi) in 2008. Guangxi, a multiethnic region located in southeastern China, has witnessed an alarming increase of HIV cases in the past decade. A total of 69,548 HIV/AIDS cases were reported in June 2011, placing Guangxi second among 31 Chinese provinces in terms of HIV seropositive cases. In the first half of 2009, on average, 30 new cases were reported each day, placing Guangxi first in the nation in terms of new cases reported. The HIV epidemiological trend in Guangxi is similar to that of greater China. Typically, injecting drug users were the major source of HIV infection, but sexual transmission has increased so rapidly in recent years that it accounted for 65% of new infections from 2008 to 2009. HIV prevalence among FSWs ranged from 1% to 11% in sentinel surveillance sites in Guangxi (Guangxi Center for Disease Control and Prevention [CDC], 2009).

B City is located in the southern part of Guangxi and has a population more than1 million people in the metropolitan area, including an urban population of 550,000. The city is famous for its beautiful beaches and attracts more than four million tourists each year. Because of significant tourism, commercial sex flourishes in the city. The local CDC estimated there were at least 155 commercial sex venues, including hair salons, massage parlors, sauna houses, nightclubs and karaoke (KTV) houses, roadside restaurants, bath centers, and small hotels in the urban areas, with an estimated 1,565 FSWs. Furthermore, there were several locations where women solicited business along the seashore and had sex with male clients in the sea or on the beach (i.e., “swimming companions”). An additional 1,000 FSWs worked in nonvenue-based places or suburban areas, totaling an estimated 2,500 FSWs in the metropolitan area.

Interview Guide

An interview guide was developed based on the theory of gatekeepers (Corra & Willer 2002), structural HIV prevention (Shannon et al., 2008), literature on commercial sex in China (Choi & Holroyd, 2007; Huang et al., 2004), and our previous ethnographic studies with FSWs in Guangxi (Hong et al., 2008). Key stakeholders, including FSWs, gatekeepers, local community leaders (both formal and informal), health care providers, government officials, and project staff provided input for the guide, which was designed to elicit information regarding the personal and social experiences of FSWs and gatekeepers.

The resulting interview guide consisted of open-ended questions with suggested probes covering several broad topics: (a) personal experience in the sex trade and in working venues; (b) the relationship between FSWs and gatekeepers; (c) HIV-related risks to FSWs; (d) barriers to HIV prevention; (e) the role of gatekeepers in decision making by FSWs; and (f) effective programs to reduce HIV risk among FSWs, as well as the role of gatekeepers in implementing these programs. The interview guide included open-ended questions to encourage extended responses.

Participants and Data Collection

The research team and local health workers first constructed a sampling scheme by stratifying the target venues that were known to provide sexual services based on their size, type, and services through ethnographic mapping. Second, we approached the establishments in each stratum according to the sampling scheme. After establishing a rapport with the venue owners, we explained the purpose of the study and asked for their participation. Once we received consent from the gatekeepers to participate, local outreach workers approached eligible women at the establishments, explained the purpose, procedures, potential benefits, and potential risks of the study, and invited them to participate.

Women were informed that participation in the study was completely voluntary and that they could withdraw from that study at any time. Approximately one third of the venues and 30% of the women we approached declined to participate. Because of study protocol on confidentiality and voluntary participation, we did not obtain information regarding the reasons for refusal. At each venue identified, we asked between one and three FSWs to participate. A total of 16 gatekeepers and 38 FSWs participated in the study.

Individual, in-depth interviews were conducted in places convenient for the participants. Interviews took place in private rooms at the venue, in hotel rooms, or in private rooms provided by the local CDC. All interviewers were proficient in qualitative interviewing and had prior research experience with FSWs. Each participant was assured of confidentiality in the study and provided with written informed consent before the interview started. Each interview took about 60 to 90 minutes. No financial incentive was provided for participation. All interviews were audio-recorded and transcribed. The study protocol was approved by the Institutional Review Boards (IRBs) of Texas A&M University and Wayne State University in the United States and Beijing Normal University in China.

Data Analysis

All interview transcripts and field notes were entered into ATLAS.ti (v6.0). Data analysis followed the procedure outlined by Ryan and Bernard (2000): theme identification, codebook building, text mark up, model construction (i.e., identification of relationships among the codes), and model testing against empirical data. Preliminary coding started with the reading and rereading of the transcripts by the research team members. Coding themes were developed from the interview guide and new themes emerged during the interview and coding process (LeCompte & Schensul, 1999; Rubin & Rubin, 1995; Silverman, 1993).

In the second stage of data analysis, two researchers independently coded all transcripts using the themes developed in the first phase and following the procedures outlined in recent qualitative literature (La Pelle, 2004; Ryan, 2004). Interrater reliability was 80%. Coding disagreements were reconciled successfully after discussion with all research team members. Detailed summaries with substantial retention of original quotes were prepared to facilitate discussion and elaboration. Quote excerpts and summaries were then categorized by participant characteristics and the coding domains; they were further compared and reviewed for interrelationships and correspondence with coding and a conceptual framework (Rubin & Rubin, 1995; Ryan & Bernard, 2000). The findings presented in this article reflect the range of responses, with some indication of the more consistent responses.

Participant Characteristics

We interviewed 16 gatekeepers and 38 FSWs. The ages of gatekeepers ranged from 20 to 60, with a mean age of 39 years. Of these gatekeepers, 5 were men and 11 were women; 5 were owners of massage parlors, 4 were managers or supervisors of saunas or massage parlors at hotels, 3 were from hair-washing rooms, and the remaining 3 worked at a KTV, card-playing house, and roadside restaurant (i.e., a roadside brothel that provides both dining and sexual services), respectively. The sizes of venues, as measured by the number of FSWs, varied from 5 to 30 FSWs. Recruited FSWs worked in nightclubs, hotel saunas, massage parlors, hair-washing rooms, or at the beach/on the street. In addition to these venue-based services, some FSWs also worked as a “second wives,” providing long-term sexual services to married men.

These women ranged in age from 18 to 44, with a median age of 30 years. Significant age differences were observed among women working at different locations. Women working in hotel saunas were the youngest, with a mean age of 20, whereas women working at the beach as swimming companions had an average age of 38. The street-based FSWs were the oldest, with a mean age of 42. Most FSWs had other legitimate occupations before working as FSWs; however, 5 FSWs entered commercial sex as their first job. The length of time working in the sex industry varied from 10 days to more than 10 years. Women working at high-paying venues had a much shorter tenure at their current venue compared to peers who worked at low-paying venues. About two thirds of the participants had stable sexual partners and half of them had children who lived in their hometown.

Venue Operation and Employment Arrangement

Three main types of working relationships were identified between FSWs and gatekeepers in B city. The first type, live-in FSWs, featured close monitoring and control by the gatekeeper, and was commonly seen in low-paying venues such as massage parlors. In such venues, FSWs called their gatekeeper “boss” and the gatekeeper usually owned the establishment. Housing and work were typically combined to save costs, and FSWs lived with their managers in the same building. One woman revealed, “We all live and work here. The first floor is a reception area, the second floor is where the massage rooms are, the third floor is for the boss, and we live on the fourth floor” (FSW, age 24 [24], massage parlor [MP]).

In this type of operation, the gatekeeper provided a space for the FSWs to meet clients and a watchful eye for potential law enforcement or abusive clients. The gatekeeper charged the clients an hourly rate for providing the space, and FSWs kept tips from clients. In B city, the typical cover charge was 20 yuan (about $3.25USD) per hour for most small commercial sex venues. The boss and FSW each kept 10 yuan, and clients offered extra tips to FSWs for each sexual service. Gatekeepers always liked a client to stay longer for sexual services so they could collect more hourly charges. FSWs had relatively less freedom in these venues because they shared space with a gatekeeper nearly 24 hours a day. FSWs were more likely to obey the rules than to advocate for change. A boss remarked, “Most of my girls are quite stable because we provide them with housing and food. With food and lodging, it is easy for them [to stay]” (Gatekeeper [G], male [M], 36, MP).

The second type of commercial sex operation was employment-based. It was commonly seen in KTV. In this type of operation, the gatekeeper usually was not an employee or owner, but a contractor. The gatekeeper, known as “mommy,” was usually a former FSW who supervised a group of 10 to 80 FSWs. The gatekeeper arranged for clients to meet FSWs, who accompanied clients on outings that included singing, drinking, and chatting prior to sexual services. FSWs were not paid by the venue. They kept tips from clients, but were required to pay daily commission to their mommy, regardless of their income level. In this kind of operation, FSWs had more autonomy; they were able to choose their mommy and played a more active role in constructing the rules of their sex trade.

Another type of employment-based operation was seen in venue-based establishments (e.g., hotel-based saunas and massage parlors). Gatekeepers were usually managers of the hotels and they were in charge of scheduling clients, negotiating price, and receiving payment. FSWs were usually not allowed to leave the hotel with clients, and their salary was typically paid on a daily basis by the hotel based on the number of clients and types of services they performed. In general, these venues were well equipped (e.g., air conditioning, massage apparatus, or spa) and clients were charged high rates. FSWs usually received 50% of the total payment that clients paid for their services. Compared to the mommy-managed framework, manager-managed FSWs were more stable in their employment and drank or smoked much less compared to peers who worked in nightclubs or KTVs.

In the third type of operation, self-employment, gatekeepers had the least control over FSWs. With the availability of cell phones, FSWs contracted with several venues; they showed up only when a gatekeeper called to inform them of a business opportunity. These FSWs were seemingly “freelancers,” but they also relied on gatekeepers to meet clients. A gatekeeper stated, “Girls are usually not here. If a client comes up asking for a girl, I will call the girl over” (G, F, 45, hair-washing room [HWR]). Another venue owner commented on how the business operation had changed over the years:

The girls nowadays are all over the place.…Seven or eight years ago, many girls lived in this place; but nowadays, few girls live with their bosses. They would make the phone calls asking if I need any girl in my shop. They would give their phone numbers to me and I just call them when clients come. (G, M, 48, HWR)

In B City, a gatekeeper typically charged the client an hourly rate if the sexual encounter took place at the venue. If the client wished to take the FSW out, he was charged an “introduction” fee (e.g., 100 yuan, about $16USD). This procedure was typically seen in hair-washing rooms, roadside restaurants, and increasingly in other venues. With the cost of living rising, more gatekeepers would like to employ freelancers to save costs.

In contrast to FSWs who had a specific boss or venue for work, self-employed FSWs also found clients by themselves along the beach or on the street. These women tended to be older and charged lower rates for their sexual services compared to their peers in entertainment establishments or personal-service sectors. These FSWs usually charged clients an hourly rate (e.g., 30 to 50 yuan/hour) to be a swimming companion or for chatting. If clients requested sexual services, FSWs negotiated a fee of one to several hundred yuan. Although these FSWs did not have a fixed gatekeeper to supervise or arrange their business, they usually lived together and had an opinion leader who played an influential role in their life. One FSW commented,

Although we don’t have a boss to arrange our business, we do have a lead who is in charge of dozens of misses in this area. She gets along with us very well and she usually distributes free condoms and provides information regarding testing and counseling services to us. We also ask for help from her if we get into any trouble. (FSW, 33, swimming companion [SC])

Interdependent and Reciprocal Relationships

In venue-based commercial sex, gatekeepers relied on FSWs to make money. In most of the operation styles described above, the gatekeeper collected a good portion of money from the FSWs; more importantly, gatekeepers provided a safe place for FSWs to meet clients and protected FSWs from abuse (Yi et al., 2012).

Condom-Use Policy and HIV/STI-related Communication in the Venues

Regardless of working and living conditions, keeping FSWs healthy and attractive was in the best interest of the gatekeepers. Although gatekeepers were concerned with the general health of FSWs, their attitudes toward condom use, especially communication regarding condom use within the venues, varied substantially. Such differences were less related to the venue type and more related to the trust and intimacy between FSWs and gatekeepers. In venues where FSWs and gatekeepers were closer, the topics of condom use or general health were often brought up, although sometimes the information provided by the gatekeepers was not completely accurate:

I am always concerned with their health. I tell them to pay more attention to their personal hygiene. They should always wash their hands after massage, and I tell them to prepare condoms. I also encourage them to douche after the services. (G, F, 60, MP)

In venues where FSWs and gatekeepers were less intimate, usually because of high turnover rates or the gatekeeper simply avoiding potential trouble, condom use communication rarely happened.

The boss never talks about condom use. He pretends he doesn’t know [the sex business]. There is no talk about condom use or HIV prevention among girls either. Nobody talks about this. We only talk about which client is rich or which is decent (FSW, age 31, massage parlor).

Gatekeepers who avoided such topics stated that FSWs had enough knowledge on this subject. One said, “I don’t need to tell them about this [condom use]. The girls today know about this more than I do” (G, F, 20, sauna in hotel [SIH]). In the venues where gatekeepers communicated about condom use or HIV/STI prevention, FSWs were more likely to report condom use with clients. Lack of communication on condom use within a venue not only reflected less intimacy between gatekeepers and FSWs, but led to less trust or loyalty from FSWs regarding their gatekeepers: “The boss doesn’t care if we have abortions. We have to take some days off and go to the hospital to take care of that, all on our money” (FSW, 26, MP).

Attitudes Toward HIV/STI-Prevention Programs

Although some gatekeepers were communicative with their FSWs regarding condom use, few were enthusiastic about organized HIV/STI-prevention programs targeting FSWs. They were concerned with the stigma associated with commercial sex, and more importantly, fearful of interruption of their business and other related troubles:

Girls would not participate in the program because they are afraid. They would feel ashamed. They don’t want to be publically identified as misses. If you organize such a program and want to have face-to-face training with girls, I could tell you most of the girls would not show up. (G, F, 45, HWR)

Some gatekeepers cited not having time or enough knowledge about prevention programs: “If we have time, we would go. We all know about condom use and all girls use condoms with clients. There is nothing more we need to learn” (G, M, 36, MP).

In contrast, FSWs showed more positive attitudes toward HIV/STI-prevention programs. Many believed that gatekeepers should also be included in the programs. For example, one proposed, “I think it is more important to train the boss, so he can remind us constantly” (FSW, 29, MP). However, most FSWs thought that receiving the training directly would benefit them more, especially those who did not trust their gatekeepers: “It is better to train the girls. The boss doesn’t care about us. He has his business to take care of. He never talks about this with us” (FSW, 21, sauna house [SH]). Having no access to such services, many FSWs had used the Internet as a source of information: “I myself often go online to look for such information. I like to know what infection I have when I have the symptoms, and how to deal with them” (FSW, 20, SH).