Incarcerated sex workers and HIV prevention in China: Social suffering and social justice countermeasures
Introduction
Contemporary sex work policies often polarize sex work as a legitimate occupation worthy of special protection (Brants, 1998) or as an immoral enterprise inseparably linked to human trafficking and crime (United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, 2003) establishing misleading theoretical dichotomies that belie the empiric complexity of social, medical, and legal issues at hand (Masenior and Beyrer, 2007, Silverman and Decker, 2007). Chinese policy responses to sex work incorporate the entire spectrum of this variation, ranging from state-run brothels and state-employed sex workers during the Ming Dynasty (1368–1644) to mandatory death sentences for sex workers during the Qing dynasty (1644–1912) (Remick, 2003). These policies often developed as local officials needed to publically support anti-prostitution social movements while still reaping the benefits of their regulatory and fiscal power over the sex trade (Sommer, 2000), informing the complex relationship between the Chinese state and sex workers that persists to this day. A Chinese resurgence in syphilis (Z.Q. Chen et al., 2007) and sexually transmitted HIV infection (Lu et al., 2008) has forced public health and political leaders to revisit this critically important and yet unanswered conundrum – how does punishing or protecting commercial sex impact the lives of those who sell sex, and what are the social and public health implications of these policies?
Anthropologic work from China suggests that wealthy businessmen in China sometimes referred to as “mobile men with money” (MMM) rely on social rituals including entertainment and sexual services in order to establish, maintain, and extend social relationships or guanxi (Uretsky, 2008). This structural context provides a stark contrast to the practice of re-education through labor (RTL) camps, a system of coercive detention for sex workers, drug users, and other marginalized groups. Considering the heterogeneity in sex worker typology in China (Huang, Henderson, Pan, & Cohen, 2004), both of these state responses can co-exist within the same socio-political architecture and within the same city (Fig. 1). This biosocial analysis of sex workers in China uses the analytic framework of social suffering (Das, 2001, Kleinman et al., 1997) to describe how administrative re-education for sex workers perpetuates physical and psychological suffering, processes that have been obscured by insufficient medical research and an emergent Chinese civil society. Examining the limited historical, legal, and public health sources on incarcerated sex workers (ISW) in China suggests a higher syphilis/HIV prevalence, but perhaps more importantly systematically suppressing social and interpersonal relationships that would be essential to helping the plight of incarcerated sex workers. Using the lens of social suffering allows us to move beyond a narrow disease framework to appreciate related forms of suffering experienced by incarcerated sex workers in China. Although a human rights framework can and has been used to analyze detention practices in China (Cohen & Amon, 2008), framing incarceration of sex workers using the concept of social suffering is both more firmly grounded in empiric findings and may be more likely to generate sustainable reform. Despite the high prevalence of HIV and syphilis among incarcerated individuals in China, there is a dearth of empiric information on incarcerated sex workers and how the process of incarceration impacts women's lives and sexual risk. This paper identifies physical and psychological suffering faced by ISW in China, comparatively interprets empiric HIV/syphilis data from Guangxi, and finally underlines medical and social transformations underway in China that could be used to catalyze reform.
Section snippets
Sex worker administrative detention and HIV in South China
In order to understand the social suffering of incarcerated sex workers in China, a brief overview of the historical and social context is important. When the Chinese Communist government took power in Mainland China in 1949, the “Temporary Regulation of Controlling Brothels” established the legal foundation to swiftly destroy the commercial sex business in China (Biddulph, 2003). On November 21, 1949, the People's Congress ordered to close down all brothels in China (Liu, 1988). On the same
Physical suffering and incarcerated sex workers in China
Social suffering refers to the sum of physical and social pain and distress endured by sex workers. Although empiric data are limited, anthropological and public health data can be used to infer the impact of punitive policies on sex workers. Physical suffering related to syphilis and HIV infection is one important mechanism whereby incarceration may work to produce social suffering. Sex workers as a whole in China face a harsh constructed environment with the potential to evoke suffering on
Psychological suffering
Beyond physical suffering inscribed in the bodies of ISW in China, implementation of policies governing incarceration of sex workers creates and reproduces social stigma. China's public security bureau and the public nature of administrative detention can reveal not only an individual's incarcerated status, but also their often previously hidden identity as sex worker (Anderson and Gil, 1994, Gil and Anderson, 1998). The urban metropolis of Shenzhen has been at the forefront of responding to
A brief empiric case study – Guangxi autonomous region
A study of over 11,000 STI clinics patients (including both incarcerated and non-incarcerated individuals) in Guangxi Autonomous Region permits a limited comparison between regional syphilis/HIV prevalence and administrative detention practices. In the context of this case study, local syphilis/HIV prevalence is used as a proxy for syphilis/HIV risk among those engaging in commercial sex since commercial sex networks are likely more important than casual sex networks in heterosexual Chinese STI
Emerging from the shadows – decreasing methodologic barriers to ISW interventions
Institutional practices and norms related to administrative detention of sex workers in China are deeply entrenched in social policy and implicit cultural assumptions, creating important methodological barriers to analytic study and intervention. A fair assessment of how to sustainably reform sex worker administrative detention in China demands an analysis of the legal, political, and medical infrastructures in place. The largely unspoken plight of incarcerated sex workers can be traced to two
Conclusion
Identifying coercive detention of sex workers in China as unique social suffering has been hindered by implicit ethical problems and the emergent Chinese civil society. Medical, legal, and social developments have created the potential to reform administrative detention policy, and perhaps even more importantly have been undergirded by changes in public perceptions of sex work. Shenzhen's “shame parade” evoked an unexpected public backlash online. Within 48 h of the original posting, over
Acknowledgements
Thanks to Professor Arthur Kleinman of the Harvard Asia Center for comments on the manuscript. Special thanks to the Gender Policy and HIV in China Working Group and Zi Teng. An earlier version of this research was presented at the University of California San Francisco VA Hospital Medical Grand Rounds and San Francisco General Hospital in 2009.
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