HIV/AIDS & Global Health: Social responsibility and Stigmatisation of Sex Workers in Ruili, China

Our third year HIV/AIDS and Global Health module, which explores broader anthropological questions around HIV/AIDS, illness and healing, sexual and reproductive relationships, and global health. As part of the module students are required to design a HIV awareness poster or research proposal. This week, we are featuring a research proposal by Nanchang Gadong on HIV on HIV, stigma and sex workers in China.

Nanchang’s bio: I am an anthropology student in my final year. I am interested in medical anthropology, music, media and education. The collaborative effort taken in the pursuit of research also intrigues me.

Empathy or blame: Social responsibility and Stigmatisation of Sex Workers in Ruili, China

Introduction

Stigmatisation results in negative consequences (Babalola, Fatusi and Anyanti, 2009) and is a barrier to ending AIDS by 2030 (UNAIDS, 2018a). Media organisations play a key role in changing public attitudes, perception and in combating HIV and AIDS (Li et al., 2009). This proposal seeks to investigate empathy, social responsibility, and the practice of advocacy amongst media professionals within the Yunnan Daily Press Group (YDPG) towards sex workers living with HIV in Ruili. The research will also explore the experience and perceptions of sex workers living with HIV to stigmatisation and YDPG journalists and their publications.

I plan to investigate the state of the narrative being shown by journalists of YDPG through their promotion, avoidance, or indifference of stigmatisation of sex workers living with HIV. I plan to do this by undertaking participant observation with YDPG journalists and plan to also undertake a survey with sex workers living with HIV in Ruili.

The proposal discusses the research questions to be explored, the epidemiological and anthropological background, and the research plan, including the ethical issues to be considered.

Research Questions

  1. How do media professionals within YDPG portray sex workers living with HIV in the media?
  2. What can be learned from the archived publications?
  3. What is the culture within the media work environment on empathy, social responsibility and advocacy towards sex workers living with HIV/AIDS?
  4. How do sex workers living with HIV in Ruili interpret stigma towards them and how does it impact them?
  5. What is the experience and perception of sex workers regarding how they are portrayed by the YDPG media?
  6. Do sex workers living with HIV feel stigmatized and is their perception that media organisations promote or reduce their feeling of stigmatisation?
  7. How do sex workers living with HIV in Ruili perceive and interpret stigma towards them and how does it affect them?

Background

Sex workers account for 4% of people infected with HIV in Asia (UNAIDS, 2018b), although the actual prevalence may be much higher (Hesketh, Zhang, and Qiang, 2005) as it is illegal to be a sex worker in China (Ma et al., 2017). Ruili is a city in Yunnan province in The People’s Republic of China and studies on HIV in this province help advise preventive strategies (Wei et al., 2015). A survey completed in 2012 showed a HIV prevalence of 18.3% in Ruili (Li et al., 2014) and by 2016, 10,198 cases of HIV had been identified and antiviral treatment was provided for free (Jiang et al., 2019) with HIV/AIDS related mortality declining by 95% compared to 2005 (UNAIDS, 2016).

Yunnan Daily Press Group is a media service providing news in Yunnan province (Cheng and Bruns, 2009). The media has largely defined the ways in which the Chinese public have increased their knowledge of HIV and AIDS by enabling local people to learn through watching (Hood, 2011). The significance of the media is expressed by the results of a survey showing that the media is where 93.4% of people in China acquire knowledge on HIV (Hood, 2011). Kleinman et al. (2011) have given the example of Shufen, a woman who became HIV positive because of a blood transfusion. The stigma she faced was accompanied by community exclusion and self-stigmatisation through fear of others. Stigma is a barrier for female sex workers to adopt preventative behaviours for HIV such as using condoms consistently, accessing HIV counselling and testing services, in addition to HIV treatment and care (Carrasco et al., 2018).

The social impact of anti-retroviral therapy (ART) includes how HIV-positive individuals express their therapeutic citizenship through bearing rights and resources through the utilisation of biological status (Nguyen et al., 2007). The impact of ART also includes the adoption of strategic social triage to allocate ART to those most valuable to a group. Value may be in terms of charismatic ability to testify on behalf of the HIV/AIDS group to receive more support. The impact of ART has been individually transformative (Nguyen et al., 2007).

Before recognition that prostitution control could not prevent the spread of STDs effectively in China, there was consensus that combating sex work was the way to combat STDs (Henriot, 1992). Innocence and guilt have been used to attribute responsibility to a person for having an illness (Sacks, 1996). In this manner, sex work is heavily associated with contagion and disease. Many discourses on AIDS suggest that HIV prevention is a result of being disciplined (Sacks, 1996). Therefore, the message that the individual should take responsibility is communicated. Professionals in the media are a group targeted for the intervention in relation to anti-stigma (Maiorano et al., 2017). The preventive model in biomedicine has promoted strong association of sexuality with potential infectiousness and dissociation of sexuality with reproduction (Bochow, 2014)

Although scholars have highlighted the need to look at stigma in terms of relationships rather than as an attribute, there has been lack of examination of the concept in this manner (Link and Phelan, 2001). Although stigma is a barrier to ending AIDS by 2030, HIV-positive beneficiaries of ART may not fear stigma as a barrier (UNAIDS, 2018; Nguyen et al., 2007). Stigma is a contributor to low treatment and testing rates in China (Kaufman, 2011).

For an actor to qualify as responsible they would need agency, being positioned to act responsibly. For society to take responsibility, they would need to act in an anti-stigma fashion, despite factors such as poverty that restrict an individual’s position and therefore agency in society. Historically it is not enough to inform an infected person that they are a carrier (Chan and Reidpath, 2003).

Whilst sex workers are newly being positioned as workers that are both legitimate and deserving of protective rights, they are also one group on which responsibility for having HIV has been placed (Hallgrimsdottir, Phillips and Benoit, 2006; Hyde, 2007). It has been indicated that operating at the level of the community will not be enough to reduce the stigma of people living with HIV (Babalola, Fatusi and Anyanti, 2009). Nevertheless, community-based empowerment approaches make use of social cohesion, connectedness among societal groups, to voice concerns and build connections. Stigma, however, has been sparingly explored as an influencer of social cohesion (Carrasco et al., 2018). In a study, social stigma has been shown to be reinforced by the practices of the media (Hallgrimsdottir, Phillips and Benoit, 2006). Other studies have shown that an improved knowledge of HIV is related positively with being informed by the media (Babalola, Fatusi and Anyanti, 2009). Over the course of research undertaken by Hallgrimsdottir, Phillips and Benoit, a shift was noted whereby there was a decline in blaming the individual sex worker and supportive community organisations, and responsibility was being placed on pimps and clients of the international trade (2006). The thematic narrative of blame has portrayed sex workers as damaged morally (Hallgrimsdottir, Phillips and Benoit, 2006).

Research Plan

I would like to undertake participant observation within the YDPG, an organisation that produces newspapers (Cheng and Bruns, 2009). This will enable the involvement of the researcher (myself) in the day-to-day activities of the participants (professionals within the YDPG). I will make use of technology to document observations, including written notes, photography, video- and audio-recording. Participant observation will help me to understand how the professionals in the media perceive their own operations as it pertains to stigmatisation of sex workers with HIV, particularly regarding empathy, social responsibility, advocacy, or blame. I would also like to utilise the period of participant observation to observe the newspapers produced by YDPG journalists, including the archives. I will particularly be focusing on media discourse relating to sex workers with HIV, to examine how the stated perception of discourse on HIV-positive sex workers by YDPG journalists compares with their actual discourse presented in the media (Bowen, 2009). I intend to engage during the participant observation by asking questions informally to understand how professionals in YDPG portray sex workers with HIV in the media and hold focus groups where possible. In addition to informal questioning, I intend to undertake semi-structured interviews with media professionals to produce audio-visual recordings, where consent is given. These semi-structured interviews will involve a questionnaire containing some prepared questions.

I would then like to also interview sex workers in Ruili, China. I would like to do this with the aim of investigating how stigma affects sex workers as well as how stigma is interpreted and perceived in relation to the actions of YDPG journalists. I aim to do this by undertaking semi-structured interviews in focus groups, allowing for the participants to discuss stigma from an emic view and provide their understanding of what it means to them and how it affects them in terms of feeling empathised with or blamed whilst avoiding the limitations of numerous guiding questions (Pool and Geissler, 2005). The interviews with the sex workers will also be recorded audio-visually if consent is given. This combination of methods will allow for triangulation in studying how the media either aids, takes responsibility or is indifferent towards stigmatisation of HIV-positive sex workers (Bowen, 2009). I would like to spend three to four months with the Yunnan Daily Press Group as going to an unfamiliar environment, this will allow for time to build relationships and familiarity before undertaking interviews.

I intend to negotiate access with Yunnan Daily Press Group by being transparent about my research intentions (Association of Social Anthropologists, 2021). Additionally, I intend to negotiate access to sex workers that are HIV positive through a sex worker NGO in Yunnan. As sex work is illegal in China, such NGOs tend not to register with authorities (Kaufman, 2011). For this reason, I intend to negotiate access with the NGOs by word of mouth and by informing them of the potential benefit for sex workers that my research could have with their assistance. I would like to negotiate access for the interviews in this way, rather than a clinic for instance, because Wong has made note of sex workers’ lack of action to utilise clinic services in Ruili (2003). I intend to access the sex workers through their NGO, as it would make the interviews with them appear as conversations by being consistent with previously brief points of discussion (Skinner, 2013).

Limitations to the approach I intend to use are that it leans towards accessing sex workers who are visible and well known, as Day avoided in her own ethnographic research (2007). This means that the results may potentially be biased. However, as the Ruili clinics have been avoided by sex workers in general and replaced with seeking peer advice and self-medicating, I will intend to go forward with accessing by word of mouth through a sex worker NGO in Ruili (Wong, 2003).

Prior to undertaking participant observation with Yunnan Daily Press Group and the sex worker NGO, I intend to apply for consent from the local authority in Yunnan and from individual participants that may be interviewed by acquiring permission for the fieldwork. I also intend to seek approval from the University of Roehampton’s Human Research Ethics Committee. I intend to maintain strict confidentiality with personal information throughout and after the research (Association of Social Anthropologists, 2021). I intend to anticipate harm by acknowledging that confidentiality has limits. I also intend to keep recorded data secure and plan to analyse the data by transcribing the recordings and organising it into themes to make inferences and recommendations (Bernard, 2011).

Political implications

Stigma remains a barrier to ending AIDS by 2030 (UNAIDS, 2018a). Understanding how media professionals conceive of and portray HIV-positive sex workers could contribute to the existing knowledge on stigma. The research could also be used to educate student journalists in China to incorporate a more reflexive approach in their work. Additionally, the research could contribute to the tailoring of HIV prevention, testing and treatment services to be more accessible to HIV positive sex workers as a result of understanding how they interpret and are affected by stigma.

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