Self-Perceived Stigma, Depressive Symptoms, and Suicidal Behaviors Among Female Sex Workers in China

Abstract

Data regarding female sex workers’ (FSWs) self-perceived stigma and their mental health are limited, particularly in developing countries. This study, using a cross-sectional survey among 310 FSWs in China, addresses this issue. Data indicate that most of these FSWs had medium to high levels of self-perceived stigma, 30% had elevated depressive symptoms, 18% had suicidal ideation, and 9% had suicidal attempt in the past 6 months. After controlling for potential confounders, FSWs’ high-level self-perceived stigma was significantly associated with their poor mental health. The authors call for culturally appropriate approaches to reduce stigma and promote psychological well-being among this marginalized and vulnerable population.

Introduction

A large body of existing literature on female sex workers (FSWs) has been focused on their risks for sexually transmitted infection (STI), including HIV. FSWs are at higher risks of infection and transmission of HIV/STI due to unprotected sex with their clients or partners. There are limited studies that focus on the psychological well-being of this population (Vanwesenbeeck, 2001). Existing literature suggests that, compared with the general population, FSWs generally have higher rates of psychopathology, including higher rates of depressive symptoms, drug use, and psychological distress (Alegria et al., 1994; El-Bassel et al., 1997; Inciardi, Surratt, Kurtz, & Weaver, 2005; Jones et al., 1998). For example, a study in Puerto Rico found that 70% of FSWs on the street had elevated depressive symptoms (Alegria et al., 1994). A study conducted in Scotland found that 53% of FSWs had thought of suicide in their life time (Gilchrist, Gruer, & Atkinson, 2005). A study conducted in the United States found that suicide accounts for 4.5% of their deaths among a cohort of FSWs (Brody, Potterat, Muth, & Woodhouse, 2005). It has been suggested that FSWs’ poor mental health is associated with stigma and discrimination they experience (Inciardi et al., 2005). Despite their recognized stigmatized status, there is a lack of empirical data on FSWs’ self-perceived stigma and its association with mental health, particularly in developing countries such as China.

In China, there has been a rapid resurgence of commercial sex in the past decades, driven and reinforced by growing economic disparities, greater freedom of population movement, increased disposable income, and the changing sexuality (Gil, Wang, Anderson, Lin, & Wu, 1996; Hong & Li, 2008). Depending on different definitions and methods used, estimated number of FSWs in China varies from 4 million to as many as 10 million (Hong & Li, 2008). Studies found that most FSWs admitted entering commercial sex voluntarily. The primary motivation is money. Many women are attracted by its quick financial return and choose sex work as a mean to support their families. Some FSWS are practicing “survival sex” as a result of poverty and limited employment opportunities (Hong & Li, 2008). A small portion of women (particularly young or underaged girls) are deceived or forced into sex trade against their will, and some women enter the profession after failure of marriage or personal relationship (Gil et al., 1996; Liao, Schensul, & Wolffers, 2003). The majority of Chinese FSWs work at entertainment establishments (e.g., karaokes, night clubs, dancing halls, discos, bars) or personal service sectors (e.g., hair-washing rooms, barbershops, massage parlors, saunas, restaurants, hotels; Huang, Henderson, Pan, & Cohen, 2004). Many of them are rural migrants in the cities with limited education and job skills (Hong & Li, 2008). Existing studies on Chinese FSWs have almost exclusively reported their heightened HIV risks and related factors; data on FSWs’ mental health are rather limited (Hong & Li, 2008).

FSWs are called “Xiaojie” (literally translated as “miss”) in China (Liao et al., 2003). It is a highly stigmatized occupation, because in Chinese culture, sex workers are generally perceived as defying acceptable social norms and roles for women (Gil et al., 1996). Women who ask for compensation for sex break traditional norms of women expected to remain virgin till marriage and stay faithful to their husbands. The traditional Chinese notion of feminist virtue, such as being gentle, quiet, stay-at-home, passive, and sexually innocent, are all dissonant with sex work (United Nation Population Fund, 2003). In addition to social stigmatization, sex work is also subject to legal discrimination. Despite its widespread existence, commercial sex is still illegal in China and condemned by the government as one of the “social evils” that is “fiercely cracked down.” The law enforcement agencies organize periodic clampdowns on the industry; FSWs and their clients are subject to fines and incarceration if arrested. Because of such double stigmatization, most of FSWs do not disclose their occupation to their family and friends and are deeply worried about such disclosure (Hong, Li, Fang, & Zhao, 2007a). Recent studies reported that FSWs in China had high rates of depression and suicidal behaviors (Hong et al., 2007a; Hong, Li, Fang, & Zhao, 2007b). But data on self-perceived stigma and its effect on FSWs’ mental health are scarce. In this study, using data collected from a sample of FSWs in Guangxi, we examined their self-perceived stigma, and the relationship between self-perceived stigma and depressive symptoms, suicidal ideation, and suicidal attempt.

Method

Study Site

The data in the current study were drawn from the baseline assessment of a longitudinal HIV/STD prevention project, which was conducted in 2006 in Liuzhou City of Guangxi Zhuang Autonomous Region (“Guangxi”). Guangxi, one of China’s five autonomous and multiethnic regions, is located in southwest China, bordering Vietnam. The prosperous economy and increased tourism in Guangxi have created a demand and market for commercial sex. With a population of 1.3 million, Liuzhou is the second largest city and the largest industrial center in Guangxi. The majority (60%) of the population in Liuzhou is Han Chinese, and the rest are minorities, with the Zhuang minority being the largest group (Liuzhou Municipal Government, 2005). Like other areas of Guangxi, there are many entertainment establishments in Liuzhou, providing commercial sex services.

Participants and Survey Procedure

We used the data collection methods that have been used in our previous study among FSWs in Guangxi (Li et al., 2006). Participants in this study were recruited from entertainment establishments such as karaoke bars, massage parlors, restaurants, barbershops, and hair-washing rooms in Liuzhou City. The research team and local health workers identified entertainment establishments in Liuzhou through ethnographic mapping. The owners/managers of these establishments were contacted for their permission to conduct research on their premises. Once we obtained permission from the establishment owners/mangers, trained outreach health workers from the City Center for Disease Control and local hospitals approached women in the establishments to ask for their participation. A total of 310 women agreed to participate, provided written informed consent, and completed a self-administered questionnaire.

The survey was conducted in separate rooms or private spaces in the establishments where participants were recruited. No one was allowed to stay with the participant during the survey except the interviewer who provided the participant any necessary assistance. The questionnaire took about 45 minutes to complete. The study protocol was approved by the institutional review boards at the funding agency and the institute where the research was conducted.

Measures

Demographic characteristics.

Women’s demographic information collected in this study included their age, ethnicity (Han, Zhuang, and other minorities), years of formal schooling, hometown type (rural vs. urban), living arrangements (alone, with family or with other FSWs), current monthly income, and length of time they have been working in commercial sex.

Self-perceived stigma.

This scale was developed based on existing literature on FSWs (El-Bassel et al., 1997; Inciardi et al., 2005; United Nations Population Fund, 2003) as well as our qualitative interviews with participants in the formative phase of the study. The scale includes five items measuring FSWs’ perception of public attitudes toward themselves (see Table 1). Cronbach’s alpha for the scale was .71. The four Likert-type scale responses ranging from strongly disagree to strongly agree were assigned values from 0 to 3, respectively. The responses across the five items were summed up and became a continuous variable ranging from 0 to 15 with higher value indicating a higher degree of perceived stigma. For the purpose of data analysis in this study, we categorized perceived stigma into three levels: low (scale score = 0–5), medium (scale score = 6–10), and high (scale score = 11–15).

Table 1.

Scale of Female Sex Workers’ Self-Perceived Stigma

Itemsa	Mean (SD)	Item-Total Correlation
1. If my friends know I am a miss, they will look down on me	1.9 (1.1)	.65
2. I think people in the society look down on me	1.5 (1.1)	.70
3. If my family knows I am a miss, they will be ashamed	2.1 (0.7)	.92
4. If I have other choices, I will not become a miss	2.4 (1.0)	.62
5. I feel I am treated as a tool, not a person	1.0 (1.1)	.63
Scale score (Cronbach’s α = .71)	8.7 (3.7)	NA

^a.Score range 0 to 3: 0, strongly disagree; 3, strongly agree.

Depressive symptoms.

Women’s depressive symptoms were measured by the Center for Epidemiologic Studies–Depression Scale (CES-D; Radloff, 1977), an instrument that has been used and validated previously in Chinese populations (Lin, 1989). In this study, Cronbach’s alpha of the CES-D scale was .89. A total score of 16 on CES-D has been accepted as a cutoff point for identifying individuals with an elevated level of depressive symptoms (Roberts & Vernon, 1983). Women with CES-D score lower than 16 were considered to have low depressive symptoms and women with CES-D score ≥16 were considered to have high depressive symptoms.

Suicidal ideation and attempt.

The questionnaire contained two questions concerning suicidality in the past 6 months: “Have you thought of committing suicide?”(yes/no) and “Have you attempted to commit suicide?” (yes/no). Those women who answered “yes” to the first question were considered to have suicidal ideation. Those women who answered “yes” to the second question were considered to have suicidal attempt.

Data Analyses

The association of perceived stigma with demographic characteristics and mental health indicators (i.e., depressive symptoms, suicidal ideation and suicidal attempt) were first tested using chi-square (for categorical variables) or analysis of variance (for continuous variables). To further examine how perceived stigma is associated with mental health when potential confounders are controlled, multivariate logistic models were built for each of the three outcome variables. Adjusted odds ratio (aOR) and 95% confidence intervals (95% CI) were calculated as the primary measures of association between the outcome and independent variables. All statistical analyses were performed using the Stata 8.0 statistical software package.

Results

Demographic Characteristics and Associations With Mental Health Indicators

The participants had a mean age of 22.5 years (range 16–42). Nearly a half of the participants were of Han ethnicity (the ethnic majority in China, accounting for 92% of the total Chinese population). Zhuang ethnicity constituted about 41% of the sample, and the remaining 9.7% were of other ethnic minorities. More than half of the women (56.8%) were from rural areas and the rest came from urban areas (including county seats, small cities and big cities). The average years of schooling were 8.5 (SD = 2.7), with 23% having elementary school education or less, 48% completing middle school education and 30% completing high school education. Their time of working as a FSW ranged from 0.5 to 96 months, with a mean of 12 (SD = 12) months. The majority (85%) of the women were single and more than one half (51%) of them lived with boyfriends or other family members; 32% lived alone and 17% lived with other FSWs. The women’s monthly income ranged from 300 to 20,000 Yuan (8 Yuan ≈ 1 US$ at the time of study), with a mean of 1783.2 Yuan.

As shown in Table 2, 20% of the women had low levels of self-perceived stigma, 44% had medium levels and 36% had high levels of self-perceived stigma. Approximately 30% of the participants had elevated depressive symptoms (with CESD score ≥16), 18% had suicidal ideation, and 9% had suicidal attempt. The level of self-perceived stigma was significantly associated with ethnicity, depressive symptoms, and suicidal attempt.

Table 2.

Demographic Characteristics and Their Association With Perceived Stigma

		Perceived Stigma
	Total	Low	Medium	High	p Value
N (%)	310 (100)	63 (20.3)	137 (44.2)	110 (35.5)
Age in years, mean (SD)	22.5 (3.9)	21.8 (3.5)	22.7 (3.9)	22.7 (4.1)	.31
Ethnicity (%)
Han	48.9	14.6	45.7	39.7	.02
Zhuang	41.4	22.7	45.3	32.0
Other minority	9.7	40.0	30.0	30.0
Hometown (%)
Urban	43.2	20.1	42.5	37.3
Rural	56.8	20.4	45.4	34.1
Education in years (%)
≤6	22.6	25.7	40.0	34.3	.76
7–9	48.1	18.8	46.3	34.9
>9	29.6	18.7	44.0	37.4
Marital status (%)
Single	85.5	19.6	46.0	34.3	.28
Married	14.5	24.4	33.3	42.2
Months of being a female sex worker (FSW), mean (SD)	12.2 (12.4)	14.5 (16.8)	10.6 (9.4)	12.9 (12.6)	.09
Living arrangement (%)
Alone	31.6	18.4	45.9	35.7	.54
With family or boyfriend	51.6	21.2	46.2	32.5
With other FSWs	16.8	21.1	34.6	44.2
Monthly income in Yuan,a mean (SD)	1741.8 (1783.2)	1710.3 (1457.7)	1553.5 (1334.4)	1994.4 (2339.7)	.15
Depressive symptomsb (%)
Low	69.7	23.15	46.3	30.6	.01
High	30.3	13.8	39.4	46.8
Suicidal ideation (%)
No	82.2	21.6	45.3	33.1	.12
Yes	17.8	14.5	38.2	47.3
Suicidal attempt (%)
No	91.0	21.3	45.7	33.0	.01
Yes	9.0	10.7	28.6	60.7

^a.Chinese currency Yuan (8 Yuan ≈ 1 US$ at the time of study).

^b.High depressive symptoms, Center for Epidemiologic Studies–Depression Scale (CESD) score ≥16; low depressive symptoms, CESD score <16.

Multivariate Analyses

As depicted in Table 3, for all three indicators of mental health (elevated depressive symptoms, suicidal ideation, and suicidal attempt), level of perceived stigma was a significant predictor. Compared with women with low-level perceived stigma, women with high-level perceived stigma were more likely to have elevated depressive symptoms (aOR = 3.2; 95%CI = 1.5–7.0), have suicidal ideation in the past 6 months (aOR = 2.9; 95% CI = 1.1–7.4) and have suicidal attempt in the past 6 months (aOR = 4.2, 95% CI = 1.1–15.8). The multivariate logistic models also indicated other risk factors of poor mental health. Specifically, women of other ethnic minorities (minorities other than Zhuang), from urban areas (as opposed to from rural areas), or with low level of education were more likely to report suicidal ideation. Women who lived with family or boyfriends (compared with living alone) were more likely to report suicidal attempt.

Table 3.

Logistic Regression of the Effect of Perceived Stigma on Depression and Suicidality

	Dependent Variables, aOR (95% CI)
Independent Variables	Depression	Suicidal Ideation	Suicidal Attempt
Perceived stigma
Low	Reference	Reference	Reference
Medium	1.9 (0.9, 4.2)	1.9 (0.7, 4.9)	1.4 (0.3, 5.8)
High	3.2 (1.5, 7.0)***	2.9 (1.1, 7.4)*	4.2 (1.1, 15.8)*
Age	0.9 (0.8, 1.0)	1.0 (0.9, 1.1)	1.1 (0.9, 1.2)
Ethnicity
Han	Reference	Reference	Reference
Zhuang	1.6 (0.9, 2.8)	1.3 (0.6, 2.6)	1.4 (0.6, 3.5)
Other minority	2.8 (1.1, 6.8)	3.4 (1.2, 9.3)*	1.8 (0.4, 7.8)
Hometown (urban vs. rural)	1.0 (0.5, 1.7)	0.5 (0.2, 0.9)*	1.1 (0.5, 2.7)
Education (years)
≤6	Reference	Reference	Reference
7–9	0.8 (0.4, 1.7)	0.4 (0.2, 0.9)*	1.0 (0.3, 3.1)
>9	0.8 (0.4, 1.7)	0.3 (0.1, 0.8)*	0.8 (0.2, 2.8)
Marital status (married vs. single)	1.2 (0.5, 2.9)	0.6 (0.2, 1.9)	0.4 (0.1, 1.7)
Length of being a FSW	1.0 (1.0, 1.0)	1.0 (1.0, 1.0)	1.0 (1.0, 1.0)
Living arrangement
Alone	Reference	Reference	Reference
With family or boyfriend	0.6 (0.4, 1.8)	1.0 (0.5, 2.0)	4.1 (1.3, 13.1)*
With other FSWs	0.8 (0.4, 1.8)	1.2 (0.5, 3.2)	2.9 (0.7, 12.3)
Monthly income	1.0 (1.0, 1.0)	1.0 (1.0, 1.0)	1.0 (1.0, 1.0)

Note: aOR = adjusted odds ratio; CI = confidence interval; FSW = female sex worker.

^*p < .05.

^**p < .01.

^***p < .005.

Discussion

The current study indicates that FSWs in China had poor mental health, with 30% having elevated depressive symptoms, 18% having suicidal ideation, and 9% having suicidal attempt in the past 6 months. Their poor mental health status was comparable with previous studies among FSWs in China (Hong et al., 2007a, 2007b). This study represents one of the first empirical studies to examine the perceived stigma of FSWs and its relationship with their mental health. Data showed that 80% of FSWs had medium or high level of perceived stigma. FSWs’ mental health was positively associated with the level of perceived stigma. Such high-level stigma and poor mental health among FSWs in China deserve more public health attention.

In China, stigmatization against FSWs is more explicit than in other countries because sex work is against the traditional Chinese values and expected social roles for women. Culturally rooted stigmatization is also engraved in legislation, and FSWs are also subject to “crack down” by law enforcement agencies including fines and incarceration. The literature has suggested that stigma at the institution or structure level is much more difficult to combat than individual-level stigma (Link & Phelan, 2001).

Previous initiatives of stigma reduction and health promotion efforts among FSWs in various international settings have shed some lights on how to reduce the stigma against FSWs. For example, in Brazil, the government works with nongovernmental organizations to design effective interventions targeting FSWs. The intervention programs have taken a tolerant, respectful approach with the government often referring to FSWs as “partners” in Brazil’s fight against AIDS. A cartoon character known as “Maria without shame” was placed on posters, leaflets, and stickers in women’s toilet facilities with the message: “You need have no shame, girl. You have a profession” (Ministry of Health of Brazil, 2002). In India, the Sonagachi Project empowered the FSWs, who played an active role in leading successful HIV prevention and health promotion programs (Jana, Basu, Rotheram-Borus, & Newman, 2004). In England, a clinical psychology service was established to provide accessible psychological and counseling services for FSWs (Stevenson & Petrak, 2007).

Given the current social and political environment in China, we do not expect the professionalization of commercial sex as in Brazil can be duplicated. Nevertheless, a more open and positive attitude as we observed in Brazil and India can be adapted. Actually, constructive policies and efforts to reduce stigma and improve psychological well-being of FSWs must be based on openly addressing the existence of this occupation, and incorporating both individual and structural factors. Although it is unrealistic to expect a rapid change in governmental policy or legislature at the national level toward commercial sex or to legalize this profession, we call for greater public awareness of FSWs’ health rights; we also advocate for practical approaches to reduce stigma and promote mental health for this marginalized and vulnerable population. For example, mental health services can be integrated with existing HIV prevention and health promotion programs. Services need to be sensitive to the barriers faced by this population. Particularly, it is necessary to create an environment where FSWs are treated with respect and cared in a nonjudgmental manner. It is also critical to involve multiple societal sectors (health care providers, policy makers, and law enforcement agencies, media) and mobilize community resources (e.g., establishments, community organizations) to provide FSWs with access to social, legal, and health services. Furthermore, economic empowerment such as educational opportunities or training for alternate job skills is necessary to reduce stigma and improve their mental health status. As previous studies suggest, most of FSWs are rural migrants without adequate education and skill training; they come to cities but cannot find jobs to support themselves and their family, and many turn to commercial sex (Hong & Li, 2008). Our data also indicate that women who were minorities, from rural areas or had low education had poorer mental health than their counterparts. Therefore, a long-term solution to reduce stigma and improve psychosocial well-being of FSWs should include economic empowerment such as equal access to education for rural girls, job skill training for unemployed women, and microcredit financing for impoverished women.

This study is limited by its cross-sectional design and its use of convenient sample. Therefore, we need to be cautious in causal interpretation and generalization of the findings. In addition, data regarding FSWs’ other psychosocial indicators such as social support and coping strategies were not collected, which limit our ability to identify the psychopathology mechanisms between perceived stigma and mental health. Nonetheless, data presented in this study suggest a high level of self-perceived stigma and poor mental health among FSWs. Appropriate public health actions are needed to reduce stigma and promote self-esteem and mental health among this marginalized population.