Journal of Drug Abuse Open Access

Introduction

Worldwide, amphetamine-type stimulants (ATS) ranked as the second commonly used illicit substances following cannabis [1]. In China, synthetic drug users accounted for nearly half of all registered drug users nationwide as of 2014 and the majority of them engaged in ATS use, which was on the rapid rise over 2014 [2].

Female sex workers (FSWs) in our study were recruited from two cities of Guangxi Zhuang Autonomous Region (Guangxi) in south-western China, which were famous for tourism and attracted millions of tourists each year. Local CDCs estimated that there were more than 2,000 FSWs working in more than 150 commercial service venues at all levels in each city [3]. Many of the FSWs were migrant workers from outside the cities or other provinces, and thought that being a FSW was a quick and easy way to make money. Evidence shows that FSWs are vulnerable to HIV infections and other sexually transmitted infections (STIs) [4- 6]. Power imbalance during sexual transactions may take effect. FSWs are likely to serve more clients and cater to client’s demand for unprotected sex in exchange for money or drugs. In Guangxi, heterosexual transmission has become the primary mode of HIV infection. Accordingly, FSWs have been more likely to be infected with HIV or other sexually transmitted diseases (STDs) by their clients.

ATS use can cause increased libido and enhance sexual pleasure, and therefore FSWs often turn to ATS use for satisfying clients or serving more clients. Moreover, ATS may have a disinhibiting effect on sexual decision-making, so FSWs are more likely to have unprotected sex after using ATS [7-10]. Therefore, ATS use is closely associated with increased sexual risk behaviors, which can in turn lead to increased rates of HIV infections or other STIs.

In China, most FSWs are unknown to their families. Even if some of them get married, they become FSWs without being known by their husbands. Most of them tend to come from economically or socially marginalized families. By being FSWs, they form their daily life circle including gatekeepers, clients and co-workers, among which they make close friends that they can confide in, and even boyfriends [11].

Given that limited data are available regarding ATS use among FSWs in China and the roles of social support in their ATS use, we aimed at identifying the present situation of ATS use among FSWs in Guangxi, China, exploring the types and sources of their perceived social support and examining the associations of both types and sources of perceived social support with their ATS use.

ATS Use among FSWs

A relatively high percentage of FSWs (19%) reported having ever engaged in ATS use, which is consistent with findings of other studies [3-5]. The majority of FSWs were younger than 29 years of age, and meanwhile those in younger age groups (≤ 23 years of age) used ATS more frequently. Younger FSWs can be favoured over their older peers and earn more for being young. In order to satisfy clients, they often use ATS to help prolong their sexual intercourse and serve more clients.

Those working in high-end entertainment venues (e.g. night clubs and bars) were more likely to engage in ATS use. Their clients can usually afford costly ATS and some of them are ATS users, and likely to either encourage the use of ATS or actively seek out ATS using FSWs to offer drug-sharing services [12,13]. High-end entertainment venues provide a safer environment to facilitate ATS use. Furthermore, FSWs may consider ATS use to be a symbol of higher class or stylishness and thus use ATS to show they conform to currently fashionable ideas [6]. Comparatively, street-based FSWs’ clients could not likely afford ATS, and meanwhile their working environment might not be safe enough to allow them to use ATS. They might choose to refrain themselves from ATS as a protective strategy and a way of maintaining some self-control [12].

Perceived social support

FSWs can come from families within which mother-father or husband-wife relationship is not so good [11]. However, FSWs in this study reported relatively higher levels of perceived social support from their families both emotionally and tangibly, although the support from families might be given under the circumstances that their offering sexual services was not known by their families. Some studies contended that FSWs should seek safety and material support from gatekeepers, emotional and information support from co-workers and spiritual and safety support from clients [14]. However, FSWs in this study did not perceive higher levels of social support from gatekeepers or clients. We believe that there is communication gap or a lack of communication between FSWs and gatekeepers or clients, which may originate from relationship power inequity between the serving and the served or the managing and the managed [4,5]. Consistent with previous studies [11,15], FSWs in our study reported higher levels of perceived social support from boyfriends, co-workers and friends.

Perceived social support and ATS use

When perceiving higher levels of emotional social support from their boyfriends, FSWs were more likely to engage in ATS use. Their boyfriends are among their close circle of friends, and might also have engaged in drug use behaviors [11]. Evidence shows that FSWs are more likely to use drugs when their sex partners are drug users [11,15]. When being emotionally supported by their boyfriends, FSWs sometimes use ATS in order to show their affinity and trust with them.

When perceiving higher levels of tangible social support from their co-workers, FSWs were more likely to engage in ATS use. Criminalization of offering sexual services in China and accompanying stigmatization can help trigger social withdrawal of FSWs, which prevents them from accessing other information channels, renders them unable to get away from the work and makes them increasingly dependent on support from their coworkers, who are likely to have engaged in ATS use, shared their experiences of using ATS and explained the corresponding benefits. FSWs, accordingly, are encouraged to use ATS in order to enjoy their co-workers’ experiences [16-20].

Conclusion

The findings help to inform the future potential ATS use reduction interventions among FSWs. Given the relative popularity of ATS use among younger FSWs, there should be a drug intervention program targeting adolescents, such as a middle school curriculum (6th, 7th and 8th grades) developed to prevent drug use [21,22]. Drug prevention and monitoring can be greatly enhanced in high-end entertainment venues where FSWs are more likely to use ATS. Promoting emotional self-reliance and effective communications with friends can help to prevent overreliance on boyfriends, emotionally. Correcting misperceptions of ATS use, strengthening their ties with drug-free friends, and providing them with sustainable income-generating alternatives can help reduce ATS use when tangible support from coworkers is perceived, and facilitate prevention of HIV and other STIs.

Acknowledgement

The study was supported by the National Institute for Alcohol Abuse and Alcoholism under grant [number R01AA018090] and by National Natural Science Foundation of China under grant [number 71203098].

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