Online commercial sex‑seeking among female sex workers in south China: a cross‑sectional study

doi:10.21203/rs.3.rs-3126748/v1

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Research Article

Online commercial sex‑seeking among female sex workers in south China: a cross‑sectional study

https://doi.org/10.21203/rs.3.rs-3126748/v1

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published 19 Oct, 2023

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Background

Online communication platforms have the potential to facilitate commercial sex among female sex workers (FSW), increasing the risk of contracting sexually transmitted diseases (STD). This study aimed to describe the patterns of online commercial sex-seeking and examine the associated factors among FSW in China.

Methods

A venue-based cross-sectional study was conducted in five cities in Guangdong Province, China, between April and October 2020. Data on socio-demographic characteristics, sexual behaviors, and online commercial sex-seeking patterns were collected through face-to-face interviews. Venous blood and urine samples were collected for STD testing. Univariate and multivariable logistic regressions were used to explore the factors associated with online commercial sex-seeking.

Results

A total of 1155 female sex workers were recruited for this study. Among them, 33.42% reported ever using online applications to seek commercial sex. The prevalence of HIV, syphilis, gonorrhea, chlamydia, and STD was 0.26%, 1.30%, 4.40%, 15.54%, and 18.39%, respectively, among FSW who had ever sought commercial sex online, which was higher than among FSW who had never sought commercial sex online. Multivariable logistic regression indicated that FSW who used online platforms to seek commercial sex were more likely to have STD (adjusted odds ratio (aOR) = 1.48, 95%CI: 1.05–2.09), experience accidental pregnancies due to commercial sex (aOR = 1.78, 95%CI: 1.21–2.62), be diagnosed as infertile (aOR = 3.20, 95%CI: 1.42–7.21), and undergo abortions (aOR = 1.69, 95%CI: 1.29–2.20).

Conclusion

A significant proportion of FSW in China engage in seeking commercial sex online, and this behavior is positively correlated with both STD and reproductive health outcomes. Given the high prevalence of online sex-seeking, it is crucial to provide a wide range of internet-based healthcare interventions and reproductive health services to Chinese FSW.

Online commercial sex‑seeking

female sex workers

sexually transmitted diseases

sexual and reproductive health

Female sex workers (FSW) bear a disproportionate burden of sexually transmitted diseases (STD), particularly in low- and middle-income countries, including China [1]. The global prevalence of infection among FSW with human immunodeficiency virus (HIV), chlamydia, gonorrhea, and syphilis ranges from 11.6–12.0%, 4.0–15.0%, 1.0–11.0%, and 1.5–42.1%, respectively [2–4]. In China, the corresponding prevalence rates are 0.2–0.8%, 5.9–25.7%, 16.4–17.3%, and 2.1–13.5%, respectively [5–10].

The advent of the internet and dating apps has led to an increase in online commercial sexual activities among FSW. Previous studies conducted in Europe and Canada have indicated that approximately 10% and 33.9% of FSW, respectively, utilize the internet to seek commercial sex [11, 12]. The prevalence of online commercial sex-seeking among FSW can be attributed to its convenience, discretion, accessibility, safety, and the ease of expanding sexual networks. However, this involvement can lead to an increased likelihood of engaging in risky sexual behaviors that facilitate STD transmission, including sexual abuse, unprotected sex, group sex, and multiple partners [13–17]. The risks associated with these behaviors are further compounded by the ongoing criminalization and stigmatization of FSW, which create barriers hindering their access to health services [18]. Nevertheless, the prevalence of online commercial sex-seeking and its associated factors among Chinese FSW remains unclear. Hence, the objective of this study is to elucidate the patterns of online commercial sex-seeking and examine the factors related to this behavior among FSW in China.

Study sites

A cross-sectional study was conducted between April and October 2020 in five cities, namely Yunfu, Jiangmen, Yingde, Rongcheng, and Puning, located in Guangdong Province, China. In each city, there was an outreach team specifically dedicated to FSW. These teams consisted of at least one public health worker and one medical staff member who possessed extensive experience in HIV/STD intervention and outreach services. Their work encompassed various activities, including sexual health education, condom distribution, HIV/STD testing and counseling, as well as facilitating the linkage to care for FSW.

Study participants

All participants were recruited through outreach services. To be eligible for participation, individuals had to meet the following inclusion criteria: 1) be biologically female; 2) be 18 years of age or older; 3) have engaged in commercial sex in exchange for goods or money at least once in the past year; 4) express willingness to participate in the survey by providing written informed consent.

Data collection

Data collection for this study utilized paper questionnaires, which were developed through discussions with the study group, international HIV/STD experts, and local outreach service workers. To ensure the validity of the survey, a pilot test was conducted with ten FSW to assess the questionnaire items and the capacity of the local outreach team. The pilot data were not included in the final analysis.

Prior to the survey, the local outreach team conducted a mapping exercise to identify the locations of sex work venues in each site, taking into account the geographical area and types of venues. The recruitment of FSW was conducted through venue-based convenience sampling, specifically targeting selected middle- and low-level venues. Middle-level venues included bath centers, nightclubs, bars, dance halls, and hotels, while low-level venues encompassed foot-bathing shops, hair salons, barber shops, roadside shops, roadside restaurants, streets, and other public outdoor areas. Face-to-face interviews were then conducted by local outreach workers with all eligible participants at their respective working venues. The survey took approximately ten minutes to complete. All survey data were treated as anonymous and confidential, and written consent was obtained prior to the commencement of the survey.

After completing the questionnaires, participants underwent testing for HIV, syphilis, gonorrhea, and chlamydia. Venous blood samples were collected from each participant for HIV and syphilis tests. HIV screening was conducted using an enzyme-linked immunoassay (Lizhu Biotech, Zhuhai, China), which was confirmed by the local Centers for Disease Control and Prevention. Syphilis testing involved the rapid plasma reagin test (Lizhu Biotech, Zhuhai, China), which was further confirmed by the treponema pallidum particle agglutination test (Rongsheng Biotech, Shanghai, China). Both the HIV and syphilis test kits were approved by the State Food and Drug Administration of China. Testing for HIV and syphilis was carried out at local sites. All urine samples were tested for gonorrhea and chlamydia using Nucleic Acid Amplification Tests (Roche Molecular Systems, Inc. New Jersey, USA) at the Dermatology Hospital of Southern Medical University. Post-test counseling and appropriate medical care for HIV/STD were provided in accordance with the Chinese standard STD clinical management guidelines.

Measurements

Social-demographic and behavioral variables

The socio-demographic information collected in this study encompassed various variables, including age, ethnicity, marital status, household registration, length of time working in the current location, highest level of education attained, and annual income. Regarding sexual behavior, the variables of interest included the average number of clients in the past week and condom usage within the past month. Additionally, reproductive health variables focused on lifetime occurrences of accidental pregnancy, infertility, and abortion.

Characteristics of online commercial sex-seeking

This study aimed to gather information on online commercial sex-seeking among participants, including whether they actively sought sexual partners online through platforms such as Weibo, websites, blogs, and apps, as well as the frequency of their social application use. For the purposes of this study, online commercial sex-seeking was defined as utilizing any online platforms to find sexual partners in exchange for goods or money. Furthermore, long-term engagement in online commercial sex-seeking referred to the continuous use of social apps for a duration exceeding one year. In this study, STD was defined as the diagnosis of any of the following conditions: syphilis, chlamydia, gonorrhea, and HIV infection.

Statistical analysis

A descriptive analysis was performed to provide an overview of the sociodemographic characteristics, sexual behaviors, reproductive health, prevalence of HIV/STD, and patterns of online commercial sex-seeking use. Univariate and multivariable logistic regression analyses were conducted to examine the factors associated with online commercial sex-seeking use, with adjustments made for age, legal marital status, education, and annual income in the multivariable model. Additionally, a sub-analysis was conducted to explore the correlates of long-term online commercial sex-seeking use among participants who had previously engaged in such activities. Statistical significance was defined as a P-value of ≤ 0.05. All data analyses were conducted using SAS 9.2 (SAS Institute Inc., Cary, NC).

Sociodemographic characteristics

A total of 1155 female sex workers, primarily from low- and middle-level venues, participated in this survey. The participants had a mean age of 33.17 ± 9.89 years. A significant proportion of the participants were under the age of 30 (40.26%, 465/1155), married (43.64%, 504/1155), had completed junior high school (53.94%, 623/1155), reported an annual income between USD 5000 and USD 10000 (33.42%, 386/1155), and had been working in their current location for over one year (40.87%, 472/1155) (Table 1).

Use of online commercial sex-seeking

Among the total of 1155 participants, 33.42% (386/1155) reported ever using the internet to seek commercial sex. A comparison between online sex-seeking users and non-online users revealed several significant differences. The online users tended to be older (P<0.001), had higher annual incomes (P<0.001), were more likely to access local health services (P<0.001), had a higher number of clients in the past week (P<0.001), had a higher proportion of accidental pregnancies (P=0.004), had a higher likelihood of experiencing infertility (P<0.001) and abortions (P<0.001), and had a higher proportion of STD cases (P=0.019) (Table 1).

Among the participants who reported ever seeking sex online, 33.94% (131/386) engaged in long-term online commercial sex-seeking. Additionally, within this group, 79.27% (306/386) had sought sexual partners online in the past week. It was found that 53.63% (207/386) of the commercial sex encounters occurred within two days of meeting the last sexual partner online. Furthermore, 61.39% (237/386) of the participants took less than 12 hours from the initial interaction to the actual meeting. In terms of protective measures, 84.20% (325/386) reported using condoms with their last online sexual partner. Interestingly, 49.48% (191/386) indicated that they would discuss condom usage before the meeting. Additionally, 34.97% (135/386) of the FSW were asked about their STD status prior to meeting up (Table 2).

Sexual behaviors, reproductive health and prevalence of HIV/STD

Out of the 1155 individuals, the average number of clients in the last week was 7.92 ± 7.23. The majority of participants reported consistent condom use during sexual encounters in the past month (72.73%, 840/1155). A small percentage of participants (11.34%, 131/1155) reported experiencing accidental pregnancies due to commercial sex, while 33.59% (388/1155) reported having had abortions. Only a minority of participants ever had chlamydia (9.00%,104/1155) and gonorrhea(7.27%,84/1155) testing, and(2.60%, 30/1155) had been diagnosed with infertility. The prevalence of HIV, syphilis, gonorrhea, chlamydia, and STD among the participants was 0.09% (1/1155), 0.87% (10/1155), 3.2% (37/1155), 12.81% (148/1155), and 14.81% (171/1155), respectively (Table 1).

Among FSW who had ever sought sex online, the prevalence of HIV, syphilis, gonorrhea, chlamydia, and STD was 0.26% (1/386), 1.30% (5/386), 4.40% (17/386), 15.54% (60/386), and 18.39% (71/386), respectively. Each of these prevalence was higher compared to FSW who had never sought commercial sex online (Table 1).

Factors associated with online sex-seeking usage

After adjusting for age, legal marital status, education, and annual income, the multivariable logistic analysis revealed several significant correlations with online commercial sex-seeking among FSW. FSW who were older (adjusted odds ratio (aOR) = 2.55, 95%CI: 1.79-3.65), had higher annual income (aOR =3.92, 95%CI: 2.47-6.23), reported receiving health services locally (aOR =2.57, 95%CI: 1.80-3.67), had a higher number of clients in the last week (aOR =2.25, 95%CI: 1.66-3.06), had experienced accidental pregnancies due to commercial sex (aOR =1.78, 95%CI: 1.21-2.62), had been diagnosed as infertile (aOR = 3.20, 95%CI: 1.42-7.21), had a history of abortions (aOR = 1.69, 95%CI: 1.29-2.20), and had a history of STD (aOR =1.48, 95%CI: 1.05-2.09) were found to be positively associated with online commercial sex-seeking. Additionally, FSW who underwent chlamydia testing (aOR =2.42, 95%CI: 1.58-3.70) and gonorrhea testing (aOR =2.60, 95%CI: 1.63-4.15) demonstrated a positive correlation with online commercial sex-seeking (Table 3).

Factors associated with long-term online sex-seeking usage

After adjusting for age, legal marital status, education, and annual income, the multivariable logistic analysis revealed significant correlations with long-term online commercial sex-seeking among FSW. FSW who had a senior high school degree and above (aOR = 7.94, 95%CI: 3.47-18.18), had a longer working duration at their current location (aOR = 13.25, 95%CI: 5.89-29.81), had fewer clients in the last week (aOR = 0.49, 95%CI: 0.28-0.86), did not experience vaginal discomfort (aOR = 3.29, 95%CI: 1.89-5.74), consistently used condoms in the last month (aOR = 3.83, 95%CI: 2.00-7.34), and had a history of abortions (aOR = 1.93, 95%CI: 1.18-3.16) demonstrated positive associations with long-term online commercial sex-seeking (Table 4).

FSW represent a high-risk group for HIV/STD transmission worldwide [1]. Online commercial sex-seeking further contributes to the escalating STD epidemic among FSW [11]. Our study aimed to shed light on the prevalence of online commercial sex-seeking among Chinese FSW and explore associated factors, thus expanding the existing literature on this topic. The findings of our study have implications for future interventions targeting online commercial sex behavior among FSW.

Our study revealed a high prevalence (33.4%) of online commercial sex-seeking among FSW in China, which aligns with findings from Canada[11] and Sweden[19], but exceeds the reported rates in Kosovo[12] and England[20]. This high prevalence may be attributed to the widespread popularity and discreet nature of the internet, which facilitates the ease of finding sexual partners. Despite efforts in many countries, including China, to restrict or monitor online sex markets (such as combating online sex trafficking and regulating sex advertising) [21], the impact of these measures remains limited. Notably, the internet has been widely utilized as a platform for delivering interventions aimed at promoting health-related behaviors on a global scale [22]. Therefore, it is crucial to consider internet-based health promotion and risk reduction interventions specifically tailored to FSW, such as disseminating sexual health text messages and risk assessments through social media, providing HIV/STD testing services, and establishing online platforms for FSW to consult with healthcare professionals [23].

Our findings highlight that FSW engaging in online commercial sex-seeking are at a higher risk of experiencing reproductive health issues, a finding that has not been consistently observed in previous studies. Several factors may contribute to this association. Firstly, online users are more likely to engage in risky sexual behaviors, such as unprotected sex, multiple partners, and group sex [13–15]. Secondly, FSW often find themselves marginalized in humanitarian contexts, resulting in their reproductive health needs being overlooked [24]. Lastly, the internet provides FSW seeking commercial sex online with increased anonymity and mobility, which can hinder healthcare providers from delivering essential health and social services to this population [25]. As online commercial sex-seeking continues to gain popularity among FSW [26], healthcare practitioners should adopt harm reduction approaches and develop innovative interventions that promote the safe use of the internet to address reproductive health concerns [15]. However, it is worth noting that existing interventions among online users primarily focus on HIV/STD prevention and individual behavior change [26], with relatively less attention given to addressing reproductive health needs [1, 27]. Therefore, we recommend the provision of comprehensive sexual and reproductive health services, including the prevention of unintended pregnancies, cervical cancer screening, and safe abortion services, specifically tailored to FSW who seek commercial sex online.

We observed alarmingly low rates of chlamydia and gonorrhea testing among the general population of FSW. Although online commercial sex-seeking FSW exhibited slightly higher testing rates compared to the general FSW population, only a small fraction of online users had ever undergone chlamydia and gonorrhea testing in their lifetime. Several factors likely contribute to these low testing rates among FSW. Firstly, the perception of STD testing as well as the fear of stigma and discrimination from healthcare providers play a role in deterring FSW from seeking testing services [28]. Secondly, the inconvenience, lack of privacy, and limited accessibility of facility-based chlamydia and gonorrhea testing further contribute to the low uptake. Lastly, for online users, the secretive and mobile nature of their online commercial sexual activities may impede healthcare providers from offering STD testing services [25]. In terms of HIV testing, there is valuable experience to draw upon in order to facilitate testing. The World Health Organization recommends innovative strategies such as social network/internet-based HIV self-testing or home-based self-collection to expand HIV testing services among hidden key populations [29]. Previous studies have demonstrated the effectiveness of these strategies in significantly increasing HIV testing rates [30, 31]. Therefore, considering the characteristics of Chinese FSW, similar approaches could be adapted to improve chlamydia and gonorrhea testing among this population.

This study has a few limitations worth mentioning. Firstly, the data on online commercial sex-seeking and sexual behaviors were collected through voluntary self-reporting, which may introduce information bias. Secondly, as this was a cross-sectional study, the observed correlations between online commercial sex-seeking and STD or reproductive health outcomes should be interpreted as associations rather than establishing causation. Lastly, the recruitment of FSW in this study was not randomized and was limited to cities with extensive experience in STD prevention, which may restrict the generalizability of the findings to cities with limited experience.

In our study, we observed a high prevalence of online commercial sex-seeking among FSW in China. This behavior was found to be positively associated with risks related to STD and reproductive health. Considering the widespread prevalence and significant implications of online commercial sex-seeking, it is crucial to develop targeted interventions that address healthcare needs and reproductive health services specifically for FSW.

FSW: Female sex workers

STD: Sexually transmitted diseases

HIV: Human immunodeficiency virus

aOR: Adjusted odds ratio

Ethics approval and consent to participate

This study received approval from the institutional review boards of the Dermatology Hospital of Southern Medical University. Prior to their participation, each patient provided written informed consent. The study was conducted in accordance with the Declaration of Helsinki, and also the local and international ethical guidelines.

Funding

This publication is supported by Medical Scientific Research Foundation of Guangdong Province (B2022139).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Acknowledgments

We are very grateful to all the participants who participated in this study. The authors wish to acknowledge Jiangmen Center for Disease Control and Prevention, Yunfu City Chronic Disease Control Center, Puning City Chronic Disease Control Center, Yingde City Chronic Disease Control Center, Rongcheng District Chronic Disease Prevention Hospital for having helped for participants recruitment. Thanks to Ye Zhang, Jinshen Wang, Haiyi Li and Peng Liang for reviewing this article.

Data Availability Statement

The dataset used in the study are available from the corresponding author on reasonable request.

Authors' Contributions

CW and PZ conceived and designed the study. CW led the implementation of the study. PZ developed the analysis plan and analyzed the data. PZ wrote the initial draft of the paper. CW, WX, RY and YS reviewed the manuscript. All authors read and approved the final manuscript.

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Table 1. Demographics and sexual behaviors of FSW in Guangdong Province, China, 2020 (N=1155).

Characteristics	Total n (%)	Online sex-seeking		P
Characteristics	Total n (%)	Yes n (%)	No n (%)	P
Demographics	1155	386(33.42)	769(66.58)
Age (Year)				<0.001
Mean±SD	33.17±9.89	34.86±10.56	32.32±9.43
<=30	465(40.26)	130(33.68)	335(43.56)
30-40	434(37.58)	145(37.56)	289(37.58)
>40	256(22.16)	111(28.76)	145(18.86)
Ethnicity				0.147
Han	1059(91.69)	347(89.90)	712(92.59)
Non-Han	96(8.31)	39(10.10)	57(7.41)
Marital status				0.620
Married	504(43.64)	164(42.49)	340(44.21)
Unmarried	651(56.36)	222(57.51)	429(55.79)
Highest education				0.125
Illiterate or primary school	250(21.65)	77(19.95)	173(22.49)
Junior high School	623(53.94)	201(52.07)	422(54.88)
Senior high school and above	282(24.42)	108(27.98)	174(22.63)
Annual income ($)				<0.001
<5000	177(15.32)	39(10.10)	138(17.95)
5000-10000	386(33.42)	103(26.68)	283(36.80)
10001-15000	345(29.87)	120(31.09)	225(29.26)
>15000	247(21.39)	124(32.12)	123(15.99)
Workplace				0.073
Middle tier	690(59.74)	216(55.96)	474(61.64)
Low tier	465(40.26)	170(44.04)	295(38.36)
Length of time working in current location (month)				0.221
<6	356(30.82)	107(27.72)	249(32.38)
6-12	327(28.31)	110(28.50)	217(28.22)
>12	472(40.87)	169(43.78)	303(39.40)
Vaginal discomfort				0.951
No	739(63.98)	246(63.73)	493(64.11)
Yes	416(36.02)	140(36.27)	276(35.89)
Received health services locally				<0.001
No	275(23.81)	49(12.69)	226(29.39)
Yes	880(76.19)	337(87.31)	543(70.61)
Sexual Behavior
Number of clients in the last week				<0.001
Mean±SD	7.92±7.23	10.06±8.50	6.84±6.24
<=7	667(57.75)	161(41.71)	506(65.80)
8-14	307(26.58)	144(37.31)	163(21.20)
>=15	181(15.67)	81(20.98)	100(13.00)
Consistent condom uses in the last month				0.970
No	315(27.27)	105(27.20)	210(27.31)
Yes	840(72.73)	281(72.80)	559(72.69)
Reproductive health
Ever had an accidental pregnancy due to commercial sex				0.004
No	1024(88.66)	327(84.72)	697(90.64)
Yes	131(11.34)	59(15.28)	72(9.36)
Ever have been diagnosed as infertile				<0.001
No	880(76.19)	317(82.12)	563(73.21)
Yes	30(2.60)	15(3.89)	15(1.95)
Unknown	245(21.21)	54(13.99)	191(24.84)
Ever abortions				<0.001
No	767(66.41)	223(57.77)	544(70.74)
Yes	388(33.59)	163(42.23)	225(29.26)
STD testing results
HIV positive				-
No	1154(99.91)	385(99.74)	769(100.00)
Yes	1(0.09)	1(0.26)	0(0.00)
Syphilis positive				0.436
No	1145(99.13)	381(98.70)	764(99.35)
Yes	10(0.87)	5(1.30)	5(0.65)
Gonorrhea positive				0.143
No	1118(96.80)	369(95.60)	749(97.40)
Yes	37(3.20)	17(4.40)	20(2.60)
Chlamydia positive				0.061
No	1007(87.19)	326(84.46)	681(88.56)
Yes	148(12.81)	60(15.54)	88(11.44)
STD positive				0.019
No	984(85.19)	315(81.61)	669(87.00)
Yes	171(14.81)	71(18.39)	100(13.00)
History of testing in the lifetime
Ever tested for chlamydia				0.001
No	1051(91.00)	333(86.27)	718(93.37)
Yes	104(9.00)	53(13.73)	51(6.63)
Ever tested for gonorrhea				0.001
No	1071(92.73)	344(89.12)	727(94.54)
Yes	84(7.27)	42(10.88)	42(5.46)

Table 2. Behaviors of FSW who ever used online to seek commercial sex in Guangdong Province, China (N=386).

Variables	n	%
Length of time since started to find sexual partners online
<6 months	107	27.72
6 months-1 year	148	38.34
1-3 years	114	29.53
>3 years	17	4.40
Engaged in finding sexual partners online in the last weeks
No	80	20.73
Yes	306	79.27
Number of sexual partners seeking online in the last week
0-3	259	67.10
4-6	99	25.65
7-10	16	4.15
>10	12	3.11
Length of time since met the last sexual partner online (days)
<1	65	16.84
1-2	142	36.79
3-4	81	20.98
5-7	55	14.25
8-30	24	6.22
>30	19	4.92
The time taken from the first interaction to meeting in reality (hours)
< 1	49	12.69
1-12	188	48.70
13-24	100	25.91
>24	49	12.69
Used condoms during last sex with the last online partner
No	61	15.80
Yes	325	84.20
Discussed about condom use before met
No	195	50.52
Yes	191	49.48
Being asked about your STD status before meeting up
No	251	65.03
Yes	135	34.97

Table 3. Factors associated with online commercial sex-seeking among FSW in Guangdong Province, China, 2020 (N=1155).

Characteristics	cOR(95%CI)	P-value	aOR(95%CI) ^#	P-value
Demographics
Age (Year)
<=30	Ref	-	Ref	-
30-40	1.29(0.97,1.72)	0.077	1.51(1.09,2.08)	0.018*
>40	1.97(1.43,2.72)	<0.001*	2.55(1.79,3.65)	<0.001*
Marital status
Married	Ref	-	Ref	-
Unmarried	1.07(0.84,1.37)	0.577	1.15(0.87,1.52)	0.322
Highest education
Illiterate or primary school	Ref	-	Ref	-
Junior high school	1.07(0.78,1.47)	0.675	0.93(0.66,1.32)	0.692
Senior high school and above	1.40(0.97,2.00)	0.070	1.09(0.72,1.65)	0.690
Annual income ($)
<5000	Ref	-	Ref	-
5000-10000	1.29(0.85,1.96)	0.239	1.25(0.81,1.91)	0.309
10001-15000	1.89(1.24,2.87)	0.003*	1.71(1.10,2.67)	0.018*
>15000	3.57(2.31,5.51)	<0.001*	3.92(2.47,6.23)	<0.001*
Workplace
Middle tier	Ref	-	Ref	-
Low tier	1.27(0.99,1.62)	0.064	1.36(1.04,1.79)	0.093
Ethnicity
Han	Ref	-	Ref	-
Non-Han	1.40(0.91,2.14)	0.119	1.12(0.72,1.75)	0.614
Length of time working in current location (month)
<6	Ref	-	Ref	-
6-12	1.18(0.86,1.63)	0.315	1.11(0.79,1.56)	0.541
>12	1.30(0.97,1.74)	0.083	1.15(0.83,1.59)	0.405
Vaginal discomfort
Yes	Ref	-	Ref	-
No	0.98(0.76,1.27)	0.900	0.83(0.63,1.08)	0.169
Received health services locally
No	Ref	-	Ref	-
Yes	2.86(2.04,4.01)	<0.001*	2.57(1.80,3.67)	<0.001*
Sexual Behavior
Number of clients in the last week
<=7	Ref	-	Ref	-
8-14	2.78(2.09,3.70)	<0.001*	2.25(1.66,3.06)	<0.001*
>=15	2.55(1.81,3.59)	<0.001*	2.09(1.46,3.00)	<0.001*
Consistent condom uses in the last month
No	Ref	-	Ref	-
Yes	1.01(0.76,1.32)	0.970	0.75(0.56,1.01)	0.058
Reproductive health
Ever had an accidental pregnancy due to commercial sex
No	Ref	-	Ref	-
Yes	1.75(1.21,2.53)	0.003*	1.78(1.21,2.62)	0.003*
Have been diagnosed as infertile
No	1.99(1.43,2.78)	<0.001*	1.57(1.10,2.23)	0.013*
Yes	3.54（1.63,7.69）	0.001*	3.20(1.42,7.21)	0.005*
Unknown	Ref	-	Ref	-
Ever abortions
No	Ref	-	Ref	-
Yes	1.77(1.37,2.28)	<0.001*	1.69(1.29,2.20)	<0.001*
STD testing results
Syphilis positive
No	Ref	-	Ref	-
Yes	2.01(0.58,9.67)	0.274	2.67(0.75,9.52)	0.131
Gonorrhea positive
No	Ref	-	Ref	-
Yes	1.73(0.89,3.33)	0.104	1.38(0.69,2.76)	0.361
Chlamydia positive
No	Ref	-	Ref	-
Yes	1.42(1.00,2.03)	0.050	1.37(0.95,1.97)	0.096
STD positive
No	Ref	-	Ref	-
Yes	1.51(1.08,2.10)	0.015*	1.48(1.05,2.09)	0.026*
History of testing
Ever tested for chlamydia
No	Ref	-	Ref	-
Yes	2.24(1.49,3.36)	<0.001*	2.42(1.58,3.70)	<0.001*
Ever tested for gonorrhea
No	Ref	-	Ref	-
Yes	2.11(1.35,3.30)	0.001*	2.60(1.63,4.15)	<0.001*

Note: #Age, legal marital status, education and annual income were adjusted for each other, and all other variables were adjusted for age, legal marital status, education and annual income.

* P<0.05.

Table 4. Factors associated with long-term online commercial sex-seeking among FSW who ever used online to seek sex in Guangdong Province, China (N=386)

Characteristics	Total n (%)	Short term use n (%)	Long-term use n (%)	cOR(95%CI)	aOR(95%CI) #
Demographics	386	255(66.06)	131(33.94)
Age (Year)
<=30	130(33.68)	94(36.86)	36(27.48)	Ref	Ref
30-40	145(37.56）	85(33.33)	60(45.80)	1.84(1.11,3.06) *	1.62(0.88,3.00)
>40	111(28.76)	76(29.80)	35(26.72)	1.20(0.69,2.09)	1.63(0.83,3.19)
Marital status
Married	164(42.49)	93(36.47)	71(54.20)	Ref	Ref
Unmarried	222(57.51)	162(63.53)	60(45.80)	0.49(0.32,0.74) *	0.78(0.47,1.30)
Highest education
Illiterate or primary school	77(19.95)	65(25.49)	12(9.16)	Ref	Ref
Junior high school	201(52.07)	146(57.25)	55(41.98）	2.04(1.02,4.07) *	1.73(0.82,3.64)
Senior high school and above	108(27.98)	44(17.25)	64(48.85)	7.88(3.81,16.28) *	7.94(3.47,18.18) *
Annual income ($)
<5000	39(10.10)	26(10.20)	13(9.92)	Ref	Ref
5000-10000	103(26.68)	86(33.73)	17(12.98)	0.40(0.17,0.92) *	0.36(0.14,0.88) *
10001-15000	120(31.09)	57(22.35)	63(48.09)	2.21(1.04,4.71) *	1.64(0.73,3.70)
>15000	124(32.12)	86(33.73)	38(29.01)	0.88(0.41,1.90)	0.60(0.25,1.46)
Workplace
Middle tier	216(55.96)	157(61.57)	59(45.04)	Ref	Ref
Low tier	170(44.04)	98(38.43)	72(54.96)	1.96(1.28,3.00) *	2.35(1.37,4.03) *
Ethnicity
Han	347(89.90)	236(92.55)	111(84.73)	Ref	Ref
Non-Han	39(10.10)	19(7.45)	20(15.27)	2.24(1.15,4.36) *	2.11(1.01,4.42) *
Length of time working in current location (month)
<6	107(27.72)	98(38.43)	9(6.87)	Ref	Ref
6-12	110(28.50)	88(34.51)	22(16.79)	2.72(1.19,6.23) *	2.89(1.18,7.07) *
>12	169(43.78)	69(27.06)	100(76.34）	15.78(7.47,33.36) *	13.25(5.89,29.81) *
Vaginal discomfort
Yes	140(36.27)	112(43.92)	28(21.37)	Ref	Ref
No	246(63.73)	143(56.08)	103(78.63)	2.88(1.77,4.68) *	3.29(1.89,5.74) *
Received health services locally
No	49(12.69)	36(14.12)	13(9.92)	Ref	Ref
Yes	337(87.31)	219(85.88)	118(90.08)	1.49(0.76,2.92)	1.01(0.46,2.20)
Sexual Behavior
Number of clients in the last week
<=7	161(41.71)	83(32.55)	78(59.54)	Ref	Ref
8-14	144(37.31)	106(41.57)	38(29.01)	0.38(0.24,0.62) *	0.49(0.28,0.86) *
>=15	81(20.98)	66(25.88)	15(11.45)	0.24(0.13,0.46) *	0.27(0.13,0.55) *
Consistent condom uses in the last month
No	105(27.20)	90(35.29)	15(11.45)	Ref	Ref
Yes	281(72.80)	165(64.71)	116(88.55)	4.22(2.32,7.65) *	3.83(2.00,7.34) *
Reproductive health
Ever had an accidental pregnancy due to commercial sex
No	327(84.72)	212(83.14)	115(87.79)	Ref	Ref
Yes	59(15.28)	43(16.86)	16(12.21)	0.69(0.37,1.27)	0.86(0.43,1.69)
Have been diagnosed as infertile
No	317(82.12)	193(75.69)	124(94.66)	8.03(3.18,27.06) *	8.55(3.25,29.58) *
Yes	15(3.89)	12(4.71)	3(2.29)	3.12(0.56,16.09)	3.73(0.61,21.03)
Unknown	54(13.99)	50(19.61)	4(3.05)	Ref	Ref
Ever abortions
No	223(57.77)	157(61.57)	66(50.38)	Ref	Ref
Yes	163(42.23)	98(38.43)	65(49.62)	1.58(1.03,2.42) *	1.93(1.18,3.16) *
STD testing results
HIV positive
No	385(99.74)	254(99.61)	131(100.0)	-	-
Yes	1(0.26)	1(0.39)	0(0.0)	-	-
Syphilis positive
No	381(98.70)	250(98.04)	131(100.0)	-	-
Yes	5(1.30)	5(1.96)	0(0.0)	-	-
Gonorrhea positive
No	369(95.6)	242(94.90)	127(96.95)	Ref	Ref
Yes	17(4.40)	13(5.10)	4(3.05)	0.59(0.19,1.84)	0.77(0.22,2.62)
Chlamydia positive
No	326(84.46)	219(85.88)	107(81.68)	Ref	Ref
Yes	60(15.54)	36(14.12)	24(18.32)	1.36(0.78,2.40)	1.67(0.87,3.20)
STD positive
No	315(81.61)	209(81.96)	106(80.92)	Ref	Ref
Yes	71(18.39)	46(18.04)	25(19.08)	1.07(0.62,1.84)	1.27(0.68,2.37)
History of testing
Ever tested for chlamydia
No	333(86.27)	211(82.75)	122(93.13)	Ref	Ref
Yes	53(13.73)	44(17.25)	9(6.87)	0.35(0.17,0.75) *	0.40(0.18,0.91) *
Ever tested for gonorrhea
No	344(89.12)	221(86.67)	123(93.89)	Ref	Ref
Yes	42(10.88)	34(13.33)	8(6.11)	0.42(0.19,0.94) *	0.60(0.25,1.45) *

Note: #Age, legal marital status, education and annual income were adjusted for each other, and all other variables were adjusted for age, legal marital status, education and annual income.

* P<0.05.

No competing interests reported.

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Online commercial sex‑seeking among female sex workers in south China: a cross‑sectional study

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Background

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Social-demographic and behavioral variables

Characteristics of online commercial sex-seeking

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