This study of 1287 FSW from eight Chinese cities reveals that a history of sexualized drug use identified FSW who had greater associations with negative sexual and reproductive health outcomes, even after accounting for injecting drug use (a known risk factor for negative health outcomes in FSW). Whilst much has been published about the associations between injecting drug use and negative sexual and reproductive health outcomes,21, 23–33 our study contribute to the limited literature on sexualized drug use among FSW, and provides evidence to support routinely asking about sexualized drug use, which may also help to more efficiently allocating resources to subpopulations of FSW with the greatest health needs.
The self-report of sexualized drug use among FSW compounded their risks for sexual health outcomes, compared to their non-drug using peers. It is already established that injecting drug use among FSW is associated with increased risks of STIs,21, 23–27 HIV,21, 26, 28 higher unintended pregnancy rates,21 reproductive morbidity,29 less consistent condom use,21, 30, 31 violence,29, 32, 33 and mental health problems.33 We add to this literature by demonstrating a history of sexualized drug use is also associated with negative sexual and reproductive health outcomes. Our disaggregated data of FSW reporting sexualized drug use uncovered significant differences in sociodemographic characteristics, sexual behaviors and HIV/STI testing behaviors compared with their non-drug using peers. This emphasizes the need to measure sexualized drug use among FSW as an additional risk factor for negative health outcomes, and thus direct additional resources to them such as empowerment-based harm reduction programs,34 or strength-based interventions.35
Sexualized drug use was commonly associated with shorter durations of sex work. This may suggest some situational issues about entering the trade that may increase risk. Whilst we were unable to ask about the complex reasons for sexualized drug use, which could pull or push FSW into using drugs, our findings are consistent with international literature. A study from Chinese FSW found that client request and monetary incentives were reasons for drug use with clients.21 This is similar to experiences of FSW from other countries where FSW earned money to sustain their drug habit36 or directly exchange of sex for crack (cocaine).37 In addition, ongoing drug-injecting among FSW was associated with having drug-using love-mates and drug-using clients among FSW in Vietnam.14
The main strength of our study is acquiring data from a large number of FSW working in diverse locations, with varying duration of time working in the sex industry. Our data, disaggregated by sexualized drug use, is a unique contribution to the current literature on FSW and highlights the unique challenges faced by a distinct group of sexualized drug-using FSW. Our findings should be read in light of several limitations. This was not a random sample although we attempted to recruit a representative sample of FSW working in diverse settings. There is a risk of social desirability bias as we relied on self-report of drug use, consistent with other studies regarding drug-use. We tried to mitigate this bias by the anonymous nature of the survey. We did not include questions regarding the use of alcohol before or during sex, which may also increase the risk of HIV/STIs in FSW.38 Given the brief nature of the survey, we did not ask about how drug-use affected the lives of the women, and we could not distinguish between non-problematic and problematic drug use. More research is needed to explore the drug related harms of sexualized drug use for FSW. Finally, we did not include males or transgender sex workers who may have even higher risk for HIV/STIs. This will be the subject of future research.