Prevalence and Patterns of Extramarital Sex among Chinese Men and Women: 2000-2015.

Despite growing concern about the "sexual revolution" in China in the past decades, empirical evidence regarding the national trends in prevalence and patterns of extramarital sex (EMS) remains sparse. This study aimed to fill this gap, using data from a population-based, repeated cross-sectional survey administered at four time points during the period 2000-2015. EMS was assessed by asking whether a person in marriage had engaged in sexual activity with someone else during the relationship with his/her current partner. Our findings showed that among married adults aged 20-59, the occurrence rate of EMS nearly tripled over the period 2000-2015, increasing from 12.9% to 33.4% for men, and from 4.7% to 11.4% for women. Moreover, in the early years of this century, EMS was negatively associated with older age (50-59 years), lower educational level (elementary and below) and rural residence for men, and negatively associated with older age and positively associated with higher educational level (college and above) for women. All these differences, however, disappeared in more recent years. Overall, this study indicates a marked increase in EMS, a widening gender gap in EMS, and for each gender, a convergence of EMS across various sociodemographic groups.

Government crackdown of sex work in China: responses from female sex workers and implications for their health.

The Chinese Government periodically enforces anti-prostitution laws through regular police presence in red light districts and through the arrests of brothel managers and sex workers. One of the most intense crackdowns on prostitution occurred throughout China in 2010. Using the 'structure-agency' framework and ethnographic approach, this paper examines the influence of the 2010 government anti-prostitution crackdown on female sex workers (FSWs). We observed 10 red light districts (6 cities and 2 counties) and interviewed 107 FSWs, 26 managers and 37 outreach workers working with FSWs. The findings describe variations in police practices and diverse strategies adopted by FSWs in response to police actions. The strategies include: soliciting sex outside of establishments in less visible channels, increasing the mobility and flexibility of sex work, changing sexual practices, sharing knowledge of how to identify policemen disguised as male clients and building personal relationships with local police. Our study suggests that, rather than disappearing as a result of crackdowns, the terms and content of sex work changed as a result of the FSWs' responses to police practices. Some of these responses potentially increased the health risks associated with sex work, but others laid the foundation for an effective response to police practices.

Understanding the meaning of short-term, yiyeqing relationships and how they are formed: implications for condom use in Liuzhou, China.

Yiyeqing (YYQ) ("one night love", i.e., having sex only once with a non-commercial partner) has increased in China, concomitant with the increase in heterosexual transmission of sexually transmitted infections/human immunodeficiency virus (STI/HIV). Our study explored how participants who had experienced YYQ understood these relationships and characterized YYQ's links to sexual risk behaviors. We conducted in-depth interviews with 45 adults in Liuzhou, a city in southwest China, who had YYQ experience. We analyzed the findings using social construction to interpret the participants' understandings of YYQ. Participants reported that they tend to select YYQ partners whom they trust, which is built through introductions from social connections and within entertainment venues, resulting in the belief that their partners are free of STI/HIV and do not require protected sex. As YYQ relationships become more common, understanding the nature of these relationships is critical for developing public health messages that convey the risks associated with sex in short-term relationships and the need for condoms.

Brief non-commercial sexual encounters among patrons of entertainment venues in Liuzhou, China.

Brief non-commercial sexual encounters among patrons of social venues are increasing in China, but whether these encounters increase syphilis risk is unknown. We surveyed and tested 797 men and women at randomly selected social venues in urban Liuzhou and three surrounding counties. The percent reporting recent non-commercial one-time sex ranged from 14.5% of county women to 24.8% of urban men. 2.4% of men and 3.7% of women had a positive rapid syphilis test. Men reporting non-commercial one-time sex were significantly more likely to have a positive rapid syphilis test than other men (7.4 vs. 0.9%). Among women, commercial sex was more strongly associated with syphilis than non-commercial one-time sex (6.0 vs. 0.7%). Recent one-time sex was common and associated with syphilis among men. Venue-based HIV/STI prevention methods may be warranted among persons who do not engage in commercial sex, but frequently engage in one-time sex.

Social contexts of heterosexual transmission of HIV/STI in Liuzhou City, China.

In this special issue of AIDS and Behavior, we focus on the social contexts of sexual transmission of HIV/STI in one South China city. Our multiple projects grew from partnerships across the social and biomedical sciences, and with public health experts in Liuzhou City, to address critical gaps in knowledge about how social factors drive heterosexual transmission. The eleven articles that comprise this special issue feature multidisciplinary and mixed method approaches, collecting data in Liuzhou from different populations, environments, and social venues where individuals often find sexual partners. They document heterosexual behaviors and their meanings. They investigate the experiences and behaviors of women and men in social venues, exploring the networks of people within these venues, how they relate to one another, share information, and influence each other. The articles also examine the experiences of people living with HIV, again collecting data from multiple levels and sources, and revealing the ongoing power of stigma to shape these lives. Taken together, the articles demonstrate the critical role of social contexts in shaping behaviors and meanings, which are linked to heterosexual transmission of HIV/STI, and which must be taken into account for the development of appropriate and effective public health interventions.

Affected by HIV stigma: interpreting results from a population survey of an urban center in Guangxi, China.

We aimed to identify factors related to HIV stigma in Liuzhou, Guangxi province, a city in southwest China with high HIV prevalence. We used a multi-stage cluster randomized sample of the general population to survey 852 adults. We conducted ordinal logistic regression analyses to test factors associated with punishment and isolation stigma. Eighteen percent of respondents agreed that people with HIV should be punished, and 40% agreed that people living with HIV (PLHIV) should be isolated. Punishment stigma was associated with age, having three or more sexual partners, and TV watching. Isolation stigma was associated with age, urban residence and a history of STI. HIV transmission knowledge was low, and having correct knowledge attenuated the association with punishment and isolation stigma. Despite programs in China to provide care and treatment for PLHIV, HIV stigma is common in this region. Targeted interventions need to focus on fears related to HIV and PLHIV.

Population-based sexual behavior surveys in China: Liuzhou compared with other prefectural cities.

Sexual behaviors in China are rapidly changing; simultaneously, sexually transmitted infections (STI)/HIV prevalence is increasing in the general population. To investigate these major shifts, we examined sexual behaviors and self-reported STI in one prefectural city in southern China, Liuzhou, and compared it to other prefectural cities throughout China. We used adults age 18-39 from two sets of population-based surveys that paralleled each other in both content and method. The first set was the Liuzhou survey conducted in 2008 (n = 398). The second set consisted of two national surveys collected in 2006 and 2010 (n = 2,186). Liuzhou respondents reported more active social and sexual behaviors than their national counterparts, including more socializing, dancing, drinking excessively, sexual activity among never married men and women, purchasing commercial sex among men, one-night stands among men, multiple sexual partnerships and self-reported STI among both men and women. Women in Liuzhou reported greater sexual risk behavior than their national counterparts, although overall they reported less than their male counterparts; they were also more likely to have had an abortion than women in other prefectural cities. Our findings provide a comprehensive overview of the sexual context of Liuzhou among the general population, which may help explain the greater STI/HIV prevalence in Liuzhou.

Sexual infidelity in China: prevalence and gender-specific correlates.

The nature of extra-relational sex in societies with rapidly changing sexual mores and widespread commercial sex remains under-explored. The 2006 Sexuality Survey of China provides a national probability survey with data on 3,567 people 18-49 years old who were in a marital (89%) or dating/cohabiting (11%) relationship. In attitudes, extramarital sex was completely unacceptable to 74% of women and 60% of men and either somewhat or completely unacceptable to 95% of women and men. Most (77%) women wanted severe punishment of men's short-term commercial sex and women's jealousy was equally elevated by their primary partner's episodes of commercial and non-commercial sex. Nevertheless, the prevalence of infidelity during the last 12 months was 4.5% (women's non-commercial sex), 11.0% (men's non-commercial), and 5.5% (men's commercial), with each percent matching or exceeding the median for other countries. In multivariate equations for non-commercial infidelity, men's infidelity was significantly more responsive to sexual dissatisfaction with his primary partner while women's was more responsive to deficits in love. In commercial sex, men were uninfluenced by primary partner deficits in love, sexual satisfaction or oral sex-pursuing, it would seem, simply a greater variety of sexual partners. In a "trading up" pattern, women partnered with low income men had elevated infidelity. The minority of women reporting early masturbation and premarital sex were just as likely as men with these backgrounds to have elevated infidelity. The Chinese patterns provide ample material for deliberations on gender similarities and differences in extra-relational sex.

Understanding the diversity of male clients of sex workers in China and the implications for HIV prevention programmes.

Male clients of sex workers have been overlooked in China's HIV prevention efforts. This study aims to examine men's practices and attitudes toward extramarital sexual relationships, motivations for visiting female sex workers (FSWs), perceptions of sexually transmitted infection (STI)/HIV risk and risk prevention strategies used. One hundred and eighty-six clients of FSWs with varying socio-economic statuses were interviewed in different sex work settings. Men described no conflict between their role as a client and a responsible family provider. They described social pressure from peers and business partners to visit FSWs, sexual pleasure and companionship as motivators to seek commercial sex. While some men reported no risks associated with visiting FSWs, others identified risks such as being arrested by the police, robbed by gangs and threatening the health of their families by contracting a STI. This study underscores the diversity of FSW clients and the need to understand the beliefs and behaviours of different client types to develop appropriate HIV prevention programmes. It also demonstrates the feasibility of recruiting different types of male clients, a hard-to-reach population for Chinese HIV prevention efforts.

Clients of female sex workers: a population-based survey of China.

The control of HIV and other sexually transmitted infections (STI) is a challenge in China, with female sex workers (FSW) and male clients suspected as bridge groups. This study used a 2006 national probability survey of 2,707 adult men. Among men 15-49 years old, the prevalence of FSW contacts last year was 4.2% (95% CI, 3.3-5.2) overall, with 7.2% (CI, 5.9-8.7) in urban and 1.8% (CI, 1.0-3.3) in rural areas. In urban areas, the men most at risk for FSW were high income, often traveled, engaged in business entertaining, ages 25-39, and had early sex histories. When compared to men with only wife or stable sex partner, those most likely to report STI last year also reported FSW sex of any type (aOR,13.10; CI, 5.87-29.42). Additionally, when compared to men reporting consistent condom use with FSW, men with inconsistent condom use had elevated STI (aOR, 3.71; CI, 1.18-11.66). Additional efforts are needed for high income men in urban areas, and on consistent condom use with FSW.

Sexual dysfunctions in urban china: a population-based national survey of men and women.

INTRODUCTION: While sexual dysfunctions are closely related to overall well-being, epidemiological data based on population-based surveys remain scant. AIM: To investigate the prevalence and correlates for sexual dysfunctions in urban China. METHODS: Of the 4,157 urbanites sampled nationally, 3,159 participants completed the interview, giving a response rate of 76%. The focus was on 78% of these participants (2,478 adults aged 20-64) who were sexually active within a stable sexual relationship, typically with the spouse. MAIN OUTCOME MEASURE: Prevalence and correlates for sexual dysfunctions. RESULTS: Fully 35% of women and 21% of men had at least one persistent sexual dysfunction. Prevalence by age was similar to the results from Western developed countries. With sharp differences for men and women, the correlates for distress in China were multiple, with aging and physical issues accounting for only a portion of the total set of mental health, stress, relationship, and values and knowledge issues related to reports of sexual dysfunctions. CONCLUSIONS: Both the prevalence and correlates for sexual dysfunctions in urban China were similar to those in other societies. Mental distress, age, and poor communication (producing the report that "my partner does not understand my sexual needs") were the correlates shared by both men and women. Other correlates were more distinct by gender. The multiplicity of correlates for men and women suggests a need for a holistic approach to sexual dysfunctions.

Sexual practices and sexual satisfaction: a population based study of Chinese urban adults.

This study examined sexual satisfaction and its social and behavioral correlates among urbanites aged 20-64 in China, using data from a nationally representative sample of 1,194 women and 1,217 men with a spouse or other long-term sexual partner with whom they had sex during the last year. The results from structural equation models suggest a multiplex set of determinants of sexual satisfaction, including relationship characteristics, sexual knowledge and personal values, physical vitality, and environmental impediments. A large proportion of the effect of these background characteristics was mediated by frequent orgasms, varied sexual practices, and perceived partner affection. In particular, much of the effect of knowledge and beliefs was mediated through variety in sexual practices. While many of the observed patterns were shared among women and men, much of the effect of relationship characteristics was mediated through perceived partner affection for women. Men, in contrast, paid greater attention to his partner's physical attractiveness and to her extramarital sex. A sexual transition is well underway in urban China, even if more rapidly for men than for women. While knowledge and values are arguably more important in this transitional period, many antecedents of sexual well-being drawn from the literature on sexual behavior in developed Western countries are also applicable to urban China.

Intimate partner violence in China: national prevalence, risk factors and associated health problems.

CONTEXT: Intimate partner violence has been studied in many developed and developing countries. China remains one of the few large societies for which the prevalence and correlates of intimate partner violence are unknown. METHODS: Data from a nationally representative sample of women and men aged 20-64 with a spouse or other steady partner provide estimates of intimate partner violence in China. Binomial and multinomial logistic regression analyses adjusted for sample design examine risk factors and negative outcomes associated with partner violence. RESULTS: Altogether, 34% of women and 18% of men had ever been hit during their current relationship; the prevalence of hitting resulting in bleeding, bruises, swelling, or severe pain and injuries was 12% for women and 5% for men. Significant risk factors for partner violence included sexual jealousy, patriarchal beliefs, low female contribution to household income, low male socioeconomic status, alcohol consumption and residence in regions other than the South and Southeast. Severe hitting was a significant risk factor for self-reported adverse general and sexual health outcomes, including sexual dysfunction, sexual dissatisfaction and unwanted sex. CONCLUSIONS: As in other societies, intimate partner violence in China is common and is correlated with adverse general and sexual health outcomes.

HIV/AIDS risk among brothel-based female sex workers in China: assessing the terms, content, and knowledge of sex work.

BACKGROUND: Sexual transmission of HIV in China is rapidly increasing, in part driven by commercial sex work. GOAL: This article examines variations in occupational control among one type of brothel-based prostitutes in China, and the relationship between the terms and content of this work and the risk of HIV/AIDS. Organizational factors are discussed as part of the current political, economic, and social context of sex work in China. STUDY: The analysis is based on ethnographic observation and in-depth interviews conducted in south China in 2000 and 2001 involving 158 female prostitutes from 45 brothels in 4 red light districts. Qualitative analysis of interview and observational data used development of thematic codes measuring occupational control. RESULTS: Brothel-based female sex workers in China are a heterogeneous population, displaying considerable variability in the organization of life and work, relationships with managers and clients, ability to negotiate condom use, knowledge of sexually transmitted diseases and HIV, and occupational identity, all of which may result in different risks of acquiring HIV. CONCLUSION: HIV prevention activities in China must focus on sociocultural aspects of sex work. Such interventions depend on detailed knowledge of its organization. The results of this study demonstrate the importance of prevention activities directed at the brothel managers and clients, as well as the sex workers.

Population-based study of chlamydial infection in China: a hidden epidemic.

CONTEXT: Sexually transmitted diseases are increasing rapidly in China. Surveillance data imperfectly indicate current prevalence and risk factors. OBJECTIVES: To estimate the prevalence of genital chlamydial and gonococcal infections and to describe patterns of infection by subgroup and behavioral patterns. DESIGN, SETTING, AND PARTICIPANTS: A national stratified probability sample of 3426 Chinese individuals (1738 women and 1688 men) aged 20 to 64 years, who were interviewed between August 1999 and August 2000, completed a computer-administered survey, and provided a urine specimen (69% total participation rate). MAIN OUTCOME MEASURE: Positive test result for chlamydial or gonococcal infections. RESULTS: The overall prevalence per 100 population of chlamydial infection was 2.6 (95% confidence interval [CI], 1.6-4.1) for women and 2.1 (95% CI, 1.3-3.3) for men. For gonococcal infection, the overall prevalence per 100 population was 0.08 (95% CI, 0.02-0.4) for women and 0.02 (95% CI, 0.005-0.1) for men. Risk factors for chlamydial infection among men aged 20 to 44 years were unprotected sex with a commercial sex worker (odds ratio [OR], 8.24; 95% CI, 3.51-19.35), less education (OR, 7.20; 95% CI, 2.31-22.37), and recent sex with their spouse or other steady partner (OR, 7.73; 95% CI, 2.70-22.10). Among women aged 20 to 44 years, risk factors for chlamydial infection were having less education (OR, 2.82; 95% CI, 1.01-7.91) and living in a city (OR, 3.46; 95% CI, 1.67-7.18) or along the southern coast (OR, 2.16; 95% CI, 1.29-3.63) and having a spouse or other steady sexual partner who earned a high income (OR, 2.85; 95% CI, 1.11-7.29), who socialized often (OR, 2.79; 95% CI, 1.08-7.19), or who traveled less than 1 week per year (OR, 5.40; 95% CI, 1.44-20.3). CONCLUSIONS: The prevalence of chlamydial infection in China is substantial. The patterns of infection suggest potential avenues for intervention.