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Reducing harm associated with selling and purchasing sex is an important public health priority in China, yet there are few examples of sustainable, successful programs to promote sexual health among female sex workers. The purpose of this study was to examine social networks among low-income female sex workers in South China to determine their potential for sexual health promotion. These data suggested that sex worker's laoxiang hometown social connections were more powerful than relationships between women selling sex at the same venue in establishing the terms and risk of commercial sex.
Female sex workers from the same hometown often migrated to the city with their laoxiang and these social connections fulfilled many of the functions of nongovernmental organizations, including collective mobilization, condom promotion, violence mitigation, and promotion of health-seeking behaviors. Further research on dyadic interpersonal relationships between female sex workers, group dynamics and norm establishment, and the social network characteristics are needed.
This is an open-access article distributed under the terms of the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The funders had no role in study de, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist. Several studies have identified social influences as important determinants of condom use among female sex workers . Reducing harm associated with sex work requires an understanding of the social and cultural context of commercial sex . Sex worker mobilization through nongovernmental organizations NGOs is dependent Local sex female the local context, much more common in India, Canada, the United States, and other places with an active civil society  and less common in China Singapore, and Vietnam.
Here we define civil society as self-governing, non-state associations that identify and address collective interests . Both model public health programs and sex work research have assumed the presence of NGOs to serve vulnerable sex workers since government-affiliated organizations may not be trusted or closely connected to female sex workers.
Rural Chinese women often migrate to urban regions in search of higher paying jobs, but then encounter adversity in urban areas in identifying and maintaining these positions . Common themes in the demographics e. In the context of our research, these laoxiang ties are defined by women coming from the same region who migrate to the same municipality. Social science research has shown how these laoxiang social ties provide durable social cohesion among labor protesters Local sex femaleentrepreneurs and business leaders women and other groups .
The migrant life experience may exacerbate sexual risk for laoxiang in the Chinese context. China has an alarming burden of syphilis  and increasing sexually transmitted HIV in some regions . A substantial of female sex workers in China are rural-to-urban migrants  and rural-to-urban migration among a subset of female migrants may increase sexual risk in China .
The experience of rural-to-urban migration for women in China can distance them from home-based social Local sex female and situate them in an environment that promotes sexual risk taking . Furthermore, female migrant sex Local sex female may have problems accessing health insurance and other local resources away from their official rural residence . China's health insurance system is undergoing reform but the extent to which female migrants have access to basic health services in urban areas is limited . Qualitative research may be particularly useful for better understanding behavioral sex worker interventions since decisions about condom use reflect a complex interplay of individual, community, and social factors .
There have been no studies in China focused on how social networks could be used to promote sexual health among female sex workers. The goal of this study was to investigate the influence of laoxiang social networks on female sex worker condom use, capacity to deal with anti-prostitution campaigns, and health seeking behaviors. This qualitative analysis included both semi-structured interviews of female sex workers and health outreach members, in addition to direct observation at entertainment centers where sex is sold.
All participants provided verbal consent because there was no more than minimal risk associated with participating in this study and no biological samples were collected. All interviewers ed forms indicating that verbal Local sex female had been obtained for each participant.
This consent procedure was approved by both IRBs prior to study launch. Increasingly social and environmental factors are recognized as critical in establishing a risk environment in which female sex workers live and work . Examining structural elements of sexual risk still appreciates variations in individual risk behaviors and decisions, but also situates individual behaviors in appropriate larger social contexts to interpret sexual risk.
This framework examines the larger social and structural factors that influence individual sexual behaviors without making assumptions about sex worker agency. In the context of female commercial sex in China, key social structures for women include sex venue relationships with managers if presentoutreach worker relationships, and fellow sex worker relationships. This choice of framework guided our decision to include both female sex workers and health outreach workers as part of the study. A Local sex female of 34 low-income sex workers were interviewed in three Pearl River Delta Guangdong Province municipalities during two phases from December through July The study population was women who sold sex in the past month for less than five US dollars per client, referred to as low-income sex workers.
An expanding literature supports increased sexual risk among low-income female sex workers in China . These Local sex female purposive sampling dimensions were selected based on our behavioral-structural framework and prior research in China suggesting that sex venue occupational characteristics and social support  are important determinants of sexual risk. The interviewers were Chinese or Chinese-Americans who received training in interview techniques.
One of the three interviewers was involved in local health outreach campaigns and already known to the participants while two other interviewers were not known to participants before the study. The choice of domains was informed by our behavioral-structural framework.
Names and contact information were not collected and each interview was ased a unique numerical identifier. Participants were given a small gift and provided sexual health and violence prevention resources. Interviews lasted 45—60 minutes and three participants had a second follow-up interview.
The purpose of the second interview was to expand on topics that were not sufficiently developed during the first interview. A total of 28 outreach members were interviewed, with 13 individuals having both outreach and physician responsibilities currently Local sex female in the past. Outreach members were local public health officials tasked to sex worker outreach programs who had substantive experience conducting outreach programs specifically Local sex female to improve sex worker health. Interviews occurred following the female sex worker interviews so that themes from the female sex workers could be discussed among outreach members.
The substantive format of the outreach member interviews was analogous to female sex worker interviews. If participants were willing to have their interviews recorded, data was digitally recorded and transcribed into Mandarin Chinese. If women were not willing to be recorded, a research assistant took notes during the interview. All textual analysis was done in Mandarin Chinese. The analysis started with KW and JT independently reviewing the transcripts to develop a list of main themes related to the role of social networks in women's sexual risk taking.
Data were collected in two waves to inform recruitment and purposive sampling and further distinguish emergent themes. Themes were identified based on the data. Coding of data was undertaken in two phases — first to identify major broad themes and then to delineate subtopics of importance within each of the broad themes.
Coding was done Local sex female software and descriptively organized by theme. Among the 34 low-income sex worker participants, the average age was 38 years old. All women were married and had Local sex female least one. The terms laoxiang or laoxiang jiemei were translated as hometown social network contact, referring to the women who migrated from the same region. All the women reported having laoxiang sisters in the area, with a range of 3—15, median of nine.
This laoxiang social network included both women who sold sex and those who did not, but all of these network members lived in the same urban municipality as the participant. Many women also reported that they would either lend cases 28, 29, 35 or borrow cases 28, 29, 33, 35 money from laoxiang. These social relationships included women who knew their laoxiang prior to migration and those who met laoxiang only after migrating to the urban destination.
There were several mechanisms whereby laoxiang sisters influenced condom use: promoting wholesale condom purchasing; mediating condom use with clients; and providing options for managing clients who refused condom use. The Local sex female organization of laoxiang sisters facilitated wholesale condom purchasing Supporting Information S1. Sex workers reported receiving condoms from outreach members Local sex female specific programs, but there were no long-term programs or STI clinic based distribution programs. Several outreach members reported that condom distribution programs were sporadic and linked to provincial programs with specific end dates OM 4, OM In order to ensure a consistent supply of condoms, a group of laoxiang sisters collectively negotiated less expensive condom prices through a wholesale operation case 26, 27, 28; Supporting Information S1.
Women reported that purchasing at least a certain amount allowed them to save money and Local sex female the added benefit of free delivery to their venue case Although it was not clear from this sample if non- laoxiang contacts participated in the wholesale purchasing, the social network allowed women to more efficiently purchase condoms. Local sex female sex workers who shared a common hometown consulted each other about condom use and condom negotiation.
Several women reported that they first learned about condom use from another woman with the same hometown cases 26—29, 31—32, A client purchasing [sex] who is unwilling to use a condom …. At the same time, two women reported only positive influences on condom use from their laoxiang cases 29, Male clients who absolutely refused condom use would encounter conflict in such tightly knit communities, resulting in arguments, collective responses, and sometimes police involvement. Women reported that laoxiang structures were important in backing them up when facing belligerent clients cases 12, 20, 24, 27—33; Supporting Information S1.
If a client tried to force non-condom use, one woman reported that she would shout to her nearby laoxiang case 12 while another would use her mobile phone to relay the message to her social network case This analysis was not able to differentiate the balance between giving and providing help with difficult clients, although four women identified an older laoxiang cases 20, 24, 27—28 female sex worker who was particularly savvy with providing help to women in condom negotiation. This level of commitment to one's laoxiang social network did not extend to other women selling sex at the venue unless they were also from the same hometown cases 27, 30, 32, Laoxiang social networks served as a social support system during anti-prostitution campaigns.
Women from laoxiang social networks would call each other if police were soon to implement a Strike Hard campaign cases 1, 7. This advance notice of police campaigns included the following three steps: social network members maintained relationships with both police and the local neighborhood committee in order to gain access to information, hometown social networks communicated with each other via mobile phones preceding campaigns, and laoxiang social networks were strengthened during police campaigns since women would often engage in communal activities card playing, mahjong, etc.
Two members of a laoxiang network reported that their connections with the local neighborhood committee were instrumental in anticipating anti-prostitution campaigns cases 12, These observations were further supported by four outreach workers who noted that women would call their laoxiang prior to anti-prostitution raids.
Now the local neighborhood committee investigates and the police only care about finding clients near the lake.
Not all laoxiang networks had forewarning of police Strike Hard anti-prostitution campaigns. Participant observation noted that women at a larger sex venue with smaller social networks Local sex female less forewarning of anti-prostitution campaigns and less trust in those working at the same venue. This site also had been subject to more regular anti-prostitution campaigns resulting in detention and fines. Laoxiang social networks also had important implications for health seeking behaviors and developing trust in local sexual health services.
Sex worker health programs were organized almost entirely by local government-run public health programs OM 8. There was limited sex worker NGO development despite large s of sex workers in each of the urban regions. The energy had to be within you. We had to find people who were able to talk with sex workers, who understood them. Rather persistent people.
You couldn't just do it one or two days and stop. The local police dispatched people to drive us out. They didn't understand. Several women reported that they would accompany cases 28, 29, 30, 32, 35 or be accompanied cases 27, 31 by laoxiang when seeking health services. One participant reported that she trusted a local gynecologist who was from the same city in Hunan Province case 1 and another sought medical advice from an old hometown network friend who is a physician case 3.
Because I Local sex female just arrived and didn't know the place well, she Local sex female me to a friendly clinic…. Now I know all the places [clinics]. I often take laoxiang sisters to see the doctor. The theme of laoxiang sisters introducing local clinics emerged from a of women Local sex female 31, 33, Female sex workers have been the subject of many network studies describing their influence on disease transmission but few studies have analyzed the positive influence of female sex worker networks on sexual health .
Our data suggest that laoxiang ties may establish healthy behavioral norms, create relationships with outreach group members and physicians, and help to create a local environment conducive to sexual health. While other studies have investigated social connections between sex workers in China they have not focused on social networks.
To the best of our knowledge, this Local sex female the first published study to examine sex worker social networks that could be used to promote sexual health in China. Especially in the context of expanding biomedical options for HIV prevention, ranging from female condoms to pre-exposure prophylaxis, a nuanced understanding of female sex worker social networks may be crucial for translating innovative strategies into effective widespread public health campaigns. Government, non-governmental, and advocacy groups charged with organizing sex worker HIV prevention campaigns could benefit from understanding the social networks of female sex workers.
Our finding that Chinese social connections influence condom use and sexual risk is consistent with research from a of settings within and outside China. Two studies of Chinese female sex workers found that venue-level peer influences were important predictors of individual condom use . Other Chinese female sex worker studies have identified venue-level factors as important determinants of HIV infection  and STI infection but have not formally analyzed underlying network structures.
A Canadian study showed that social network norms influence individual condom use . A Brazilian analysis of female sex workers found that increased participation in social networks was associated with a decrease in frequency of unprotected sex .
The literature on how to encourage sex workers to trust local outreach staff and regularly attend clinics is sparse.Local sex female
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