Human Insecurity in the People’s Republic of China: The Vulnerability of Chinese Women to HIV/AIDS
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HIV/AIDS has become one of the world’s leading causes of human insecurity for both men and women. In addition to physiological factors, women’s vulnerability to HIV transmission is primarily fuelled by gender inequality and gender-based discrimination and violence. Therefore, women’s vulnerability to HIV transmission is closely linked to issues of empowerment and gender-based power relations. Even with this realization however, women are still sometimes overlooked in many HIV/AIDS prevention and treatment campaigns, such as those in the People’s Republic of China (PRC), and responses to HIV/AIDS do not always actively seek to empower women. Therefore, a deficiency in women’s human security increases their HIV/AIDS vulnerability. This chapter examines the intersection of gender inequality and HIV vulnerability as it applies to women in the PRC. The unequal status of many women in China, and the privileged position accorded to Chinese men, strongly indicates that Chinese women face a heightened vulnerability to HIV transmission. While many of these vulnerabilities are similar to women elsewhere in the world and certainly are not unique to China, by overlooking the many social, cultural, economic and political factors that contribute to HIV/AIDS vulnerability and transmission of the virus, particularly those faced by women, China has a long way to go before Chinese women are protected from HIV transmission. Given that HIV/AIDS heightens human insecurity, the stage is set for Chinese women (and men) to face an insecure future if the Chinese government does not fully implement international best practice, meaning a gendered response, into its overall HIV/AIDS response.
KeywordsSevere Acute Respiratory Syndrome Sexually Transmitted Infection Chinese Woman Severe Acute Respiratory Syndrome Heterosexual Intercourse
2.1 Women and HIV/AIDS in the People’s Republic of China
In China, HIV/AIDS has spread to new groups of the population and it has been estimated that around 740,000 people were living with HIV/AIDS (PLWHA) at the end of 2009 (Ministry of Health of the People’s Republic of China 2010: 5). There are serious localized HIV/AIDS epidemics in several provinces; Yunnan, Guangxi, Henan, Sichuan, Xinjiang and Guangdong. These provinces alone account for 70–80% of China’s overall HIV/AIDS rates (Ministry of Health of the People’s Republic of China 2010: 5). Xinjiang Autonomous Region and Yunnan Province have both experienced HIV/AIDS epidemics resulting from high rates of needle sharing among injecting drug users and up until 2005 the sharing of intravenous drug equipment was the main mode of HIV transmission in the PRC. In addition, blood and plasma selling to centres practising unsafe blood-donation procedures has led to approximately 69,000 former blood and plasma donors and recipients to contract HIV mainly in Henan, Hubei, Anhui, Hebei and Shanxi (National Centre for AIDS/STD Prevention and Control 2006: 1).1
Figures from the Ministry of Health (MOH) show sexual transmission is now the main mode of HIV transmission in the PRC, signalling that China has moved into the ‘growth period’ of its HIV/AIDS epidemic. At the close of 2009, it was reported that 59% of the total number of HIV/AIDS cases in China were caused by sexual transmission, with heterosexual transmission accounting for 44.3% of those infections and homosexual transmission accounting for 14.7% (Ministry of Health of the People’s Republic of China 2010: 22). Of the total reported number of HIV/AIDS cases, 30.8% of PLWHA in the PRC are women demonstrating the vulnerability of women to HIV transmission and increasing the concerns that the country is in a growth period (SCAWCO and UNAIDS 2007: 4). Also concerning is that since 2005, sexual transmission has been the fastest growing mode of HIV transmission in China (Hong et al. 2009).
Further evidence of China’s HIV epidemic moving into its growth period are the country’s figures on mother-to-child-transmission (MTCT). Since 2005, it has estimated that MTCT of HIV accounted for approximately 1.3–1.5% of the total number of new HIV cases (National Center for AIDS/STD Prevention and Control 2006: 2; Ministry of Health of the People’s Republic of China 2010: 23). According to the United Nations Joint Program on HIV/AIDS (UNAIDS) MTCT rates in excess of 1% demonstrate that a HIV/AIDS epidemic meets the criteria for the categorization of a ‘generalized epidemic’ as MTCT highlights rates of HIV among women in the general population who do not belong to any particular high-risk group (Gill et al. 2007).
Therefore, the above results are further evidence that China’s overall HIV/AIDS epidemic has moved into its growth period. If effective prevention and control measures are not introduced prior to or during the growth period, and the country’s HIV/AIDS epidemic moves into the ‘rampant prevalence period’, large scale HIV transmission is inevitable. Although rates of HIV among the general population remain low in the PRC, with rates believed to be between 0.042% and 0.071% (Ministry of Health of the People’s Republic of China 2010: 5), the spread of HIV through heterosexual intercourse among the general population is very much a warning that the numbers of PLWHA may soon explode across the country. If this occurs, it would make the epidemic very difficult to prevent and control and Chinese women’s vulnerability to HIV transmission will increase substantially, particularly because the prevalence rate of HIV among the general population would increase rapidly.
Physiologically, women are two to four times more vulnerable to HIV transmission than their male counterparts when engaging in unprotected vaginal intercourse (UNAIDS 2002: 57).2 In addition to physiological risks, women worldwide face a number of vulnerabilities to HIV/AIDS, deriving from a variety of social, cultural, economic and political factors. A society’s gender roles have considerable influence on three main areas of HIV/AIDS vulnerability; accurate sexual and reproductive health knowledge, sexual passivity and aggression, and promiscuity. In addition, ‘enabling environments’ such as social, cultural, political and economic environments, can all fuel HIV vulnerability among women and these vulnerabilities are largely the result of gender inequality (Feinstein and Prentice 2000).
Thus, in order for a state’s HIV/AIDS response to be effective it must include gender-specific factors. Therefore, women must be recognized as a vulnerable group. However, when asked whether she believed Chinese women were particularly vulnerable to HIV transmission, Interviewee D (2003, pers. comm., 27 August),3 who was the Director of a government organization that played a key role in HIV/AIDS prevention and treatment, responded that she believed ‘women are less vulnerable [than men] to HIV/AIDS’ and that women’s vulnerability to HIV/AIDS largely depended on whether a woman was a sex worker, an intravenous drug user (IDU), if she had donated her blood, had a blood transfusion or had used other blood products (Interviewee D 2003, pers. comm., 27 August).
This point of view was supported by another interviewee, who was the National Programme Officer for an international non-governmental organization (INGO) responsible for HIV/AIDS prevention and treatment. In response to the same question, this interviewee stated that ‘gender does not play any role [in its HIV/AIDS policies], and it is not part of mainstream discussions’ (Interviewee C 2003, pers. comm., 22 August). These responses are alarming because they ignore the patterns of HIV transmission to women in much of the rest of the world, whereby women in the general population have been found to be extremely vulnerable to HIV transmission in areas with high rates of HIV/AIDS.4
Women are vulnerable… for a number of reasons. These include the status of women - political, economic and social status of women. Also, the educational level of women is lower than their male counterparts, and unemployment rates are a great deal higher. This has a lot to do with remaining views on the role of women, which follow closely with the traditional stereotypes of women as wives, devoted to house and raising children. They are still seen in this caregiver role. Women are also restricted in their access to information, so this also makes them vulnerable because they don’t know what HIV/AIDS is or how to prevent it (Interviewee C 2003, pers. comm., 22 August).
Responses from other interviewees also demonstrated that organizations were aware of the links between gender and HIV vulnerability. When asked what factors he believed increased Chinese women’s vulnerability to HIV/AIDS, Interviewee E (2003, pers. comm., 27 August), a health specialist for an INGO that included HIV/AIDS in its health framework, responded that he felt unemployment and low education levels were key factors because they led to economic insecurity that could lead women to prostitution. He stated that particularly in rural China, female school enrolments were much lower than those of males, and that this adversely affected women’s employment opportunities. He also stated that women were further disadvantaged because they were not paid the same as men for equal work. Also, because many women had been laid-off from their jobs in northeast China, due to factory closures and cutbacks, many of these women had been forced to enter the sex industry as a means of survival (Interviewee E 2003, pers. comm., 27 August).
Hence, while both Interviewees C and E were aware of the effects gender has on HIV/AIDS vulnerability, neither their particular organizations, nor any other organizations responsible for HIV/AIDS prevention and treatment campaigns at the time, incorporated gender into their programmes or education campaigns. Interviewee A, who was a Senior Programme Officer for an overseas aid agency (2003, pers. comm., 21 August), offered two possible reasons for this oversight. Firstly, she believed a gendered response was not a major component of China’s HIV/AIDS strategy because ‘gender issues are generally addressed by the All China Women’s Federation (ACWF) or the Regional Women’s Commission (RWC)’ (Interviewee A 2003, pers. comm., 21 August). Secondly, at the time of fieldwork, ordinary Chinese women among the general population were not widely recognized or targeted as being vulnerable to HIV transmission (Interviewee A 2003, pers. comm., 21 August). Therefore, according to Interviewee A, because women among the general population were not regarded as a vulnerable group it made little sense to organizations such as hers to engender their HIV/AIDS prevention strategies.
However, if we consider Interviewee A’s first response, it would appear that the ACWF and RWC have unintentionally ‘marginalized’ women in discussions on HIV/AIDS vulnerability among organizations responsible for HIV/AIDS prevention and treatment campaigns because these organizations do not want to interfere with the role of the ACWF and the RWC. This reluctance could in part be because of the historical background of the ACWF. This organization was one of the first mass organizations formed by the Chinese Communist Party following the 1949 Liberation and was the impetus for the social, legislative and policy changes aimed at improving the status of women in the 1950s. While it was temporarily disbanded during the Cultural Revolution, the organization was fully reformed in 1978 and since that time it has continued its earlier work on improving the status of women in China through legislative and social change (Howell 2003). Therefore, the ACWF has had a monopoly on women’s issues in China for much of China’s post-Liberation period.
While there has been an expansion of women’s groups and organizations since the reform and opening of China in 1978, it is significant to note that the ACWF has remained an important ally for these groups (Lee and Regan 2009), and the strongest women’s organization in China due to its political legitimacy and sway in the political structure (Howell 2003). Therefore, Interviewee A’s reasons for the lack of consideration of gender in official responses to HIV/AIDS in China demonstrates that there are serious impediments which need to be addressed. It would seem there is a reluctance to either tackle gender issues by non-ACWF organizations as they may perceive a turf war conflict, or simply because they feel that such issues are best handled by the ACWF. Whatever the reason, because such organizations are reluctant to incorporate gendered responses into their HIV/AIDS prevention and treatment campaigns women have been marginalized in the mainstream responses to HIV/AIDS in China even though international experience has repeatedly demonstrated that if they are left unresolved, gender vulnerabilities to HIV transmission fuel HIV epidemics.
However, Interviewee A did state that should the epidemic move into the ‘rampant prevalence’ period, these groups (meaning women in the general population not belonging to any of the traditional ‘high-risk’ groups) would receive more attention from organizations like hers. Thus, it would appear some organizations do believe gendered responses may be necessary in the future. Nonetheless, the reluctance of international organizations like Interviewee A’s to incorporate gendered responses was concerning as in many AIDS-stricken countries, especially those in Sub-Saharan Africa, women among the general population have been found to be at substantial risk of contracting HIV through non-commercial heterosexual intercourse (UNAIDS, UNFPA and UNIFEM 2004: 1–2). As stated above, much of this vulnerability stems from social, cultural, economic and political factors that often reflect gender inequality and this chapter now turns to an examination of these in the context of women in the PRC.
2.2 Sexual and Reproductive Health Knowledge
Accurate knowledge about HIV/AIDS, including the prevention and transmission of HIV, is an essential part of an adequate response to HIV/AIDS. However, surveys conducted by some INGOs have revealed that as much as 20–40% of China’s population has no knowledge of HIV/AIDS at all (Park 2003: 54; UNAIDS 2002: 43). While recent figures suggest this has changed and that ‘basic’5 HIV/AIDS awareness is in the vicinity of between 74.5% and 85.1% for urban and rural residents and migrant workers, there still remain pockets of the population who lack accurate HIV/AIDS knowledge and awareness (Ministry of Health of the People’s Republic of China 2010: 7). One of the reasons often cited for this lack of knowledge is that due to China’s size and regional variances in language dialects, country-wide HIV/AIDS education campaigns are difficult to conduct. Interviewee F (2003, pers. comm., 9 September), the Division Director of a government organization that examines HIV/AIDS related issues, confirmed this when she stated ‘because China is so large… not everyone knows about AIDS [and] the information has not spread to very remote areas, [therefore] more work will be done there’. These factors seriously complicate the dispersal of accurate HIV/AIDS knowledge, and are a key area that the Chinese government must overcome to effectively respond to China’s growing HIV/AIDS epidemic. However, there also exists a range of other reasons for the poor levels of HIV/AIDS knowledge in China.
The reform and opening period, which began in the late 1970s, loosened societal attitudes and views on sexual issues in China, and this resulted in an increase in premarital sex and societal acceptance of premarital sex (Qian et al. 2004; Wu et al. 2007). A study by the Sex Sociology Institute of the People’s University of China found that in people over 40 years of age, 45.7% of men and 24.1% of women reported they had engaged in premarital sex. However, for the 25–29 year old age bracket, rates were significantly higher with 72.2% of men and 46.2% of women reporting they had engaged in premarital sex (Xia 2004: 14). Even though premarital sex is occurring, sex education and the supply of contraceptive devices to young, unmarried people remains a contentious issue.
Interviewee C (2003, pers. comm., 22 August) stated that sex education was an important topic in China and that there had been much debate over when young people should be taught about sexual health, with some sections of Chinese society arguing that the university level was the most appropriate time for formalized sex education. There was also growing debate over abstinence-based sex education as opposed to sex education that promotes ‘safer sex’, such as using condoms, with the proponents of the abstinence-based sex education style hoping to see a return to ‘traditional morality’ (Xia 2004: 15). In the meantime, no real steps have been made in implementing a comprehensive sex education curriculum into Chinese schools. As a result, many university students in the PRC have ‘alarmingly low’ levels of AIDS knowledge and self-perceived risk (Wu et al. 2007: 683), reflecting the need for a national sex education curriculum. This is concerning as HIV in China is most prevalent among people in the 20–29 year old age bracket, with this group accounting for 56% of China’s overall HIV/AIDS cases (Ma et al. 2009: 249). However, these rates of infection are unsurprising when one considers that surveys of university students have found that only 15% of those who were sexually active reported 100% condom use in their sexual encounters during the year prior to the study (Ma et al. 2009: 256).
For many young unmarried people in China, the lack of accurate knowledge on ‘safer sex’ has been a contributing factor in them engaging in unprotected sex, which easily facilitates the transmission of STIs, including HIV, as well as increasing rates of unintended pregnancy. Although young unmarried people can access contraceptive services in China, information and advice about contraception is somewhat limited. This is because the National Family Planning Programme only targets married couples for the delivery of contraception information and devices. Furthermore, studies conducted in rural and urban Shanghai found that when premarital sex resulted in pregnancy, most pregnancies were unintended, and were usually because the couple had not used contraceptives (Qian et al. 2004). Surveys conducted on confidence levels when purchasing condoms found that only 44.3% of women compared to 85.5% of men felt confident buying condoms (Ma et al. 2009: 257). Clearly, even though premarital sex has become more commonplace and generally more acceptable, a comprehensive sex education programme and easy, more accepted access to reliable barrier methods of contraception are needed if optimum health outcomes are to be achieved.
Another key factor in this discussion is how condoms are perceived by Chinese society. With the resurgence of STIs in China, and the need to promote condoms effectively as a means of preventing STIs, condoms have undergone a name change from bi yun tao, or ‘avoid pregnancy sheath’, to an quan tao, or ‘safety sheath’. The change reflects the dual role of condoms in preventing conception, but also as a means of preventing the transmission of STIs/HIV (Yuan et al. 2003: 17). Interviewee F acknowledged this change, adding that her organization stressed ‘…using condoms is beneficial for men and women, from the point of view of health, because men and women will both benefit from the[ir] use’ (2003, pers. comm., 9 September). However, a recent study has reinforced that condoms are still primarily perceived by some university students as pregnancy prevention rather than protection against STIs/HIV. The study found that 95% of respondents identified condoms as protection against pregnancy while only 30–41% regarded them as protection against STIs/HIV (Ma et al. 2009: 256). Clearly, condoms are a necessary part of an effective HIV prevention strategy so it is imperative that their role in STI prevention is stressed and encouraged in the Chinese situation.
Thus, even with the name change, condom use in China remains low. This is alarming to epidemiologists because of the role of condoms in preventing STIs/HIV, particularly for women. A study by Xia in 2002 found that 75.1% of male respondents were unwilling to use condoms in their sexual relations because they found them to be ‘troublesome’, to decrease male sexual pleasure, as well as too expensive. In addition, many unmarried men preferred not to use condoms because they felt their ‘sexual and reproductive ability’ was proven if their partners became pregnant (2004: 22). Furthermore, many men continue to view their sexual relationship with their wife as procreation, whereas sexual pleasure is derived from commercial sex workers. Therefore, condoms within marriage are not considered appropriate and they are rarely used, regardless of some men having multiple sexual partners (Chen 2008).
Interviewee B (2003, pers. comm., 22 August), a Programme Officer for an overseas aid agency, believed that women could be vulnerable to STIs from their partners because ‘there is no such dialogue [safer sex] between husband and wife or partners’. Furthermore, she concluded that in south-west China for instance, promotion of condom use in sexual relationships was absolutely necessary because the main route of HIV infection for men there has been IDU and for women, it was through heterosexual intercourse ‘within the family, within marriage, it’s not through commercial sex workers’ (Interviewee B 2003, pers. comm., 22 August). Increasing condom usage rates among the general population is further complicated because many Chinese women use intra-uterine devices (IUDs) or have had surgeries such as tubal ligation or hysterectomies to avoid further pregnancies, causing condoms to be viewed as unnecessary.6 Therefore, Interviewee B believed that it was imperative condoms be promoted as a sexual health device within marriage and committed relationships in addition to persons engaging in premarital sex or infidelity.
While promoting condom use among the general population was also identified as a necessity by Interviewees D and C, work is needed on promoting 100% condom use among commercial sex workers in both their commercial and non-commercial sexual relations. In China, condom use among sex workers is also extremely low with only 10% of sex workers surveyed at various locations reporting that they always used condoms, and close to 50% of sex workers reporting that they had never used a condom with a client (Kanabus 2004). This is not surprising considering many sex workers lack adequate HIV/AIDS information in the first instance and secondly because condom use in sexual exchange generally involves a ‘discount’ due to both decreased sensitivity and male sexual pleasure. Therefore, the economic burden faced when insisting on condom use in the commercial sex exchange means that for many sex workers condom use is not a viable or desirable economic option.
In addition, low rates of HIV/AIDS and STI knowledge has meant that many sex workers do not believe they are at risk of contracting HIV. This clearly indicates a continuing lack of HIV prevention knowledge in an important ‘high-risk’ group, which increases the likelihood of the transmission of HIV among sex workers and their clients (Kanabus 2004). Furthermore, other sex workers who wanted to use condoms in the commercial sexual exchange were prevented from doing so because they lacked ‘the power to insist on the use of condoms with their clients’ (Thompson 2004). In most instances, it is the client who decides whether or not a condom is used in commercial sexual exchange, again reflecting the disempowered status sex workers face (Kanabus 2004). Hence, poor HIV/AIDS awareness and female disempowerment facilitates such ‘high-risk’ behaviour, and this situation reinforces the need for widespread public education campaigns to better educate the entire Chinese population on HIV/AIDS prevention and risk. This is particularly pressing considering that commercial sex is the leading contributing factor for the transmission of HIV through heterosexual intercourse (Hong et al. 2009). However, such an education campaign must contain accurate and appropriate messages about HIV/AIDS and HIV prevention.
2.3 Stigma, Discrimination and Self-perceived Risk
Early state media representations of HIV/AIDS negatively affected HIV/AIDS knowledge in China, and how PLWHA were received by society and by the medical profession. Interviewee D (2003, pers. comm., 27 August) stated that when the state media initially discussed HIV/AIDS, it was portrayed as ‘the enemy’ and that media reports were largely focused on scaring people about the virus. Furthermore, Interviewee D believed that these early representations greatly contributed to the stigma and discrimination of PLWHA in China. This argument was reinforced by Dikötter, who claimed that AIDS was initially described in official discourse as an ‘evil from abroad’, and that it was widely believed that the ‘superior immune system’ of the Chinese, combined with their ‘Neo-Confucian values’, would mean that HIV/AIDS would not infect the general population but would largely remain limited to homosexual men and sex workers who serviced foreign clients (1997: 78–79). Such beliefs became accepted by Chinese society and have influenced how both the virus and PLWHA are perceived.
In addition to stigma and discrimination, these early representations of HIV/AIDS have also led to many people falsely believing that they are not at risk from contracting HIV if they do not belong to one of the above-mentioned groups. This false sense of security was reflected in the section on ‘Self-perceived risk of contracting HIV/AIDS’ in a study conducted by the Futures Group (2004: 17). This study explored the levels of HIV/AIDS knowledge among respondents and their attitudes and behaviours towards AIDS related issues. The study found that 78% of those surveyed believed themselves to be at ‘low-risk’ of contracting HIV/AIDS, and that the main reason for such a belief was because very few of the respondents (2%) reported that they knew of a PLWHA or a person who had died from AIDS. Therefore, because they themselves had not known anyone affected by HIV/AIDS, their perception of the virus was that it is something that affects the ‘other’ or that it only affected ‘degraded people’ (Futures Group 2004: 17). Consequently, because they did not fit either category, they believed themselves to be of little risk of contracting HIV/AIDS.
Self-perceived risk has also been skewed by the government’s HIV/AIDS prevention policies, which have long been focused on ‘high-risk’ groups. It can be argued that current prevention strategies actually put women at risk because they stress partner reduction over condom use as an effective way to avoid HIV transmission. The ‘one partner’ or ‘faithfulness’ prevention messages, which teach both men and women to protect themselves against HIV transmission by limiting the number of partners they have to one, has been described by UNAIDS as lulling people into a ‘false safety’ (UNAIDS 2002: 44). Surveys that have been conducted in China among traditional ‘low-risk’ groups such as married women, who do not engage in any of the traditionally recognized ‘risky practices’ conducive to HIV transmission, have found that most women believe that limiting the number of partners they have to one is much better protection against HIV transmission than using condoms (UNAIDS 2002: 44). However, such a measure is dependent upon their spouse having a negative status upon the commencement of the relationship, and not engaging in practices that may cause them to contract HIV for the duration of the sexual relationship.
Furthermore, the ‘one partner’ campaign ignores the fact that for many women in the developing world who have contracted HIV/AIDS through heterosexual intercourse, the source of their transmission was their only sexual partner, usually their husband.7 Often these women were unaware of their husband’s HIV+ status, and in other cases, whereby they knew their husband was HIV+, they were unable to say no to sex or insist on condom use due to the unequal gender-based power relations within the relationship. In a study of Chinese women who contracted HIV from their husbands, none of the women interviewed were aware of their husband’s HIV+ status prior to their own diagnoses. In addition, one husband commented that he felt women ‘had little choice if their husbands insisted they do so [have sex], inasmuch as the fact that “we are still married” legitimized their sex’ (cited in Zhou 2008: 1119). Therefore, the government sponsored campaigns in China that primarily focus on individuals reducing ‘risky practices’ or limiting the number of sexual partners they have to one, are out of step with reality. Instead, HIV/AIDS prevention campaigns also need to focus on providing easily accessible sexual and reproductive health information for both men and women, and making condoms available and accessible to all sexually active persons. They should also aim to empower women and challenge the negative gender stereotypes and biases attributed to both men and women that heighten their vulnerability to HIV transmission.
2.4 Gender Stereotypes and Patriarchal Views in the PRC
Worldwide, women’s vulnerability to HIV/AIDS is further heightened in societies where women are expected to be passive towards sex. While China was, traditionally, very much a society whereby passivity was expected of women in sexual matters, after 1949 this situation was widely believed to have altered because of Mao’s proclamations about female equality as well as the belief that the ‘smashing’ of class difference would lead to the eradication of outdated sexual stereotypes regarding men and women. However, patriarchal views still permeate Chinese society and overall Chinese men retain their position of gender privilege, often reflected in the power dynamics of heterosexual relationships.
The One Child Policy is one of the main factors in increasing female insecurity in contemporary China, particularly within the marital unit. Since its introduction, there has been a strong resurgence in son preference, especially in the rural areas where sons play an important role in continuing the family lineage, contributing to the family labour force and their filial duty to provide for their parents in old age (Croll et al. 1985; Croll 2000; Chan et al. 2002). In some areas of China, the re-emergence of son preference has caused there to be strong pressure on women to give birth to a son and failure to do so can lead to domestic violence and even divorce. This is because women are wrongfully blamed over the sex of the child due to poor knowledge on the biological determinants of the sex of the fetus and also because it is believed to be ‘the duty of a Chinese wife to bear a son to continue the family name’ (Chan et al. 2002: 427).
In her discussion of son preference and the resultant violence against women who give birth to daughters, Croll provided several accounts of incidences whereby a husband committed acts of domestic violence against his wife after she bore a daughter (2000: 78–80). The ACWF has found that reported cases of domestic violence occur in approximately 30% of Chinese families, with 32.5% of abused women being beaten around four times per month (Xinhua 2000). Female suicide rates are also high in the PRC, reflecting female insecurity there. Of the total number of female suicides worldwide, 56% occurred in China (Renwick 2002: 383). In addition, while the urban rate of female suicide is estimated to be in the vicinity of 15.9 per 100,000 women, in rural areas the figures have reached 78.3 per 100,000 women, clearly demonstrating a rural/urban divide in female suicide rates in China (HRIC, cited in Renwick 2002: 383). A report by the BBC echoed these findings, and stated that many rural women are highly successful in their suicide attempts because they used pesticides and rat poisons to commit suicide (BBC 2002).
If gender-based violence such as domestic violence is viewed as an acceptable factor in preserving gender relations in the home, it can substantially increase women’s vulnerability to HIV transmission. In societies where there exists ‘a cultural ethos that violence is a valid means of solving inter-personal disputes’ (Whelan 1999: 11), such as in the domestic spheres, women may avoid discussing the use of condoms or fidelity issues with their partners for fear of violent response. The fear of violent retribution was identified by women from a range of countries such as Guatemala, Jamaica and Papua New Guinea as being the reason why they did not try to negotiate condom usage with their sexual partners (Feinstein and Prentice 2000: 24). Women’s vulnerability to HIV/AIDS is heightened by male aggression because it can often be linked to the occurrence of sexual coercion, non-consensual sex and sexual violence against women. For many women, decisions about their sexual behaviour are denied to them because they are forced into sexual intercourse against their will. This is applicable both inside and outside of relationships. In such instances, condom usage is unlikely, so women’s vulnerability to HIV transmission is increased (Irwin et al. 2003: 31). Therefore, the accounts given above of high rates of domestic violence and female suicide demonstrate that there are a great number of women in the general population who are facing increased HIV vulnerability due to their unhealthy domestic environment.
The traffic of women in China is also fuelling female vulnerability to HIV transmission, and is most prolific in Sichuan and Guizhou. Interviewee A (2003, pers. comm., 21 August) attributed this to the fact that these two provinces ‘have a high number of poor farmers and unemployed’ so they sell women for financial rewards. Interviewee A also stated that the ‘traffic of women in China is generally restricted to marriage, whereas trafficking outside of China is generally for prostitution’. In saying this, the interviewee believed that the traffic of women, while bad, would not increase the likelihood of HIV transmission because the women were sold as ‘brides’, not sex workers (Interviewee A 2003, pers. comm., 21 August). The belief that trafficked ‘brides’ are not particularly vulnerable to HIV transmission was also shared by Interviewee E (2003, pers. comm., 27 August). However, this belief demonstrates a serious lack of understanding of human trafficking as members of the trafficking gangs sometimes rape the women, regardless of them being trafficked as ‘brides’ or as sex workers. Furthermore, prospective husbands are sometimes allowed to have intercourse with the women before purchasing them, in order to decide which woman will become their ‘bride’ and also so that they can bargain the price of the woman (South China Morning Post, cited in Jaschok and Miers 1994: 264). Clearly, the rape of these women by numerous men, including their ‘husband’, increases their vulnerability to HIV transmission. In addition, the likelihood that their ‘husband’ will contract HIV from them or from other women he ‘sampled’ is also heightened if he does not already carry the virus. Hence, it is a very serious misconception that the traffic of women in China as ‘brides’ will have little impact on the HIV/AIDS epidemic there.
Equally alarming is the view held by some segments of Chinese society that ‘as long as they [men] have the money, buying a wife or child is their own affair’ (Li Zhongxiu, cited in Jaschok and Miers 1994: 265). Again, this kind of attitude illustrates the low status that many women (and children) continue to occupy in Chinese society and the patriarchal factors that heighten their vulnerability to HIV/AIDS. In addition, it is widely predicted that the sale of women in China is set to continue to expand because from a purely economic standpoint, buying a trafficked bride can be far cheaper than paying a dowry (Song, cited in Jaschok and Miers 1994: 265). Also, the skewed sex ratios that have resulted from the introduction of the One Child Policy and resultant resurgence of son preference have seen men far outnumber women in many areas of China (Edwards 2000: 75). It has been estimated that by 2029, there will be 30 million more males than females in the 20–49 year age bracket due to sex selective abortion and the neglect of girl children in China (Chan et al. 2002: 429). Due to the gender imbalance it is unlikely that these men will be able to find a bride to marry legally and they will increasingly turn to bride trafficking as the solution, making it a crime that is likely to soar over the next few decades, alongside prostitution.
While the Chinese government has not ignored this situation, and the Public Security Bureau often detects and arrests human traffickers, trafficking is difficult to police as the number of women trafficked yearly is believed to be in the vicinity of tens of thousands. They are primarily abducted from poor regions in Guizhou, Sichuan and Yunnan Provinces (Woodman and Ho, cited in Hughes et al. 1999). Further complicating this issue is the fact that many women who have escaped their ‘husbands’ have not received assistance because some authorities also have sympathy toward men who have been unable to find brides. As a result, women who escape their situation are often returned to their ‘husbands’ by authorities. Villagers also assist in the trafficking of women either by ignoring the problem, or by helping to buy women. In fact, it has been reported that one remote village collectively purchased women with the intention of soliciting them from their homes (Woodman and Ho, cited in Hughes et al. 1999). The traffic of women constitutes a serious potential bridge for HIV transmission to the general population and again reflects a heightened vulnerability, in terms of both HIV transmission and human insecurity, for Chinese women.
Another factor identified by Interviewee C as compounding the situation of women’s vulnerability to HIV transmission was the migration of rural workers to the cities for work. She stated that although many male migrant workers are married, they leave their wives behind and often engage in ‘risky practices’ in the cities, such as IDU, procuring sex workers, and infidelity. Generally, the men return to their homes once a year, during which they engage in sexual activity with their spouse, usually without using condoms. The interviewee further stated that even if the woman may suspect her spouse of having engaged in ‘risky practices’ while away, many women are unable to insist that their spouse use a condom (Interviewee C 2003, pers. comm., 22 August). In addition, for many rural women, labour migration can heighten their vulnerability to HIV transmission because it removes them from the economic support and protection nets that exist in their home villages, making them easy targets to be lured or forced into prostitution. In fact, a large number of China’s sex workers are migrant women (Thompson 2003) and they sometimes display higher risk behaviour than non-migrant sex workers, in part due to low education levels and poor HIV/AIDS awareness, which increases their likelihood of contracting HIV (Hong et al. 2009). Many migrant women have also become the victims of sexual harassment and sexual violence, which also increases their vulnerability to HIV transmission.
While conservative estimates suggest the number of sex workers in China is approximately three million (Thompson 2004) to four million (Harding 2000), scholars such as Professor Pan of People’s University of Beijing believe the figure to be much higher when the numbers of women who engage in ‘casual or infrequent transactional sex’ are included (cited in Thompson 2004). It has also been reported by UNAIDS that the Public Security Bureau estimates the number of sex workers in China could be as high as six million (UNAIDS 2002: 65). Jeffreys states that government authorities in China have called prostitution a ‘widespread and growing problem’ (2004: 83).8 Thus, a conservative estimate of four million sex workers demonstrates that a considerable number of Chinese women are vulnerable to HIV infection through prostitution.
The illegal nature of prostitution in China is a major barrier to HIV/AIDS advocacy for sex workers and continues to exacerbate the vulnerable status of sex workers. Interviewee D (2003, pers. comm., 27 August) stated that organizations like hers could give HIV prevention information to sex workers, without arresting them, because it was not a government organization. If workers from the government organizations identified sex workers, she stated that they were required to report them because of the illegality of prostitution. After being reported, the identified sex worker would then face detention in a rehabilitation centre. While there are debates in China as to whether or not prostitution should be decriminalized or legalized so as to allow INGOs, NGOs and government organizations to legally provide STI prevention knowledge and services to sex workers, the rehabilitation system does currently offer an opportunity to reach this vulnerable group with HIV/AIDS prevention information. However, Interviewee D (2003, pers. comm., 27 August) stated that this was not occurring, even though the organization she worked for had been trying to launch programs that linked ‘HIV/AIDS prevention education into the rehabilitation programs of these centres’. Furthermore, without adequate help to overcome their economic insecurity, upon release from these centres many women actually returned to prostitution. Thus, she stated, an important opportunity was being missed.
There is concern however, over the contradiction in the government’s response to prostitution, which sees sex workers targeted by interventionist programs, not those soliciting the prostitutes. This obvious gender bias is in part fuelled by the extant view in China that those selling sex always come before those buying sex. This view is problematic in that one could argue that it is demand that drives provision; however at a very basic level it punishes the sex worker as the guilty party in the commercial sex exchange and not the solicitor. It also means that many of the men who solicit prostitutes are left out of the targeted commercial sex HIV prevention strategies although they are clearly a ‘high-risk’ group (Chen 2008). If they are married or have other sexual encounters outside of the commercial sexual exchange, they are also a possible ‘bridge’ population who have the potential to transmit HIV into the general population.
Chen (2008) argues that the failure of the Chinese government to adequately respond to this contradiction reflects that there is an urgent need in China for recognition of the important role men play in safer sexual practice, a responsibility that is continually being thrust onto women. In fact, recent campaigns by the ACWF reportedly ‘exposed’ 27.25 million women across China to HIV/AIDS prevention and awareness knowledge. However, there was no discussion of if/how men were also given this important knowledge or if they were made aware of how their actions can impact on the HIV vulnerability of their spouses (SCAWCO and UNAIDS 2007). Considering the unequal gender-based power relations discussed above, it is unlikely that these types of measures will have much success as men and women both need to be involved in such advocacy programs. To neglect the involvement and importance of men serves to increase women’s vulnerability while at the same time proportioning responsibility to women for their own HIV safety, something that is simply unachievable for many women.
2.5 The Health System and Government Responses
The failure of the rural health system is also exacerbating the vulnerability of Chinese women to HIV/AIDS. Approximately 60% of rural women are now showing symptoms of having untreated RTIs or STIs (Interviewee C 2003, pers. comm., 22 August), both of which increase their susceptibility to HIV through sexual transmission (Jolly and Ying 2003: 2). The figures on STIs clearly indicate that behaviours conducive to the transmission of HIV/AIDS, such as unprotected intercourse, are becoming more widespread. However, rural healthcare facilities continue to be inadequate, and therefore information on HIV/AIDS and prevention of the virus is not reaching rural men and women (Interviewee C 2003, pers. comm., 22 August). In addition, many rural women are not targeted for information dissemination due to the official belief that these women fall into the ‘low-risk’ category due to their marital status and individual behaviour. In light of the discussion above, this overly simplistic classification of who is or is not ‘at risk’ is substantially heightening women’s vulnerability to HIV. Considering the changing face of China’s HIV/AIDS epidemic in the current era, the failure of the government to have a comprehensive gendered response to the burgeoning AIDS epidemic in the PRC may result in the government ineffectively responding to HIV/AIDS. Chen (2008) warns that this could lead to an increase in stigma and discrimination against women as their HIV+ rates increase and may further exacerbate women’s insecurity.
When critiquing the privatization of health care in China, Interviewee D (2003, pers. comm., 27 August) stated that prior to the 1990s, the health system in rural China was much better because ‘bare foot doctors and health workers were active in even the most remote areas’. However, after the dismantling of government sponsorship, the rural healthcare system was left in ruins, with only expensive private doctors available to meet the health care needs of the rural population. Another problem with the provision of health care is that the government does not regulate STI facilities. In fact, some STI clinics are now being rented out to private practitioners. While this can benefit PLWHA, because it reduces the possibility of their HIV+ status being leaked,9 it also causes prices to rise and patient care tends to decline (Interviewee C 2003, pers. comm., 22 August). Therefore, the privatization of essential services such as the health industry has seen medical services fall out of the economic reach of many poorer families or individuals. This compounds Chinese women’s vulnerability to HIV because it limits the ability of both men and women to manage their sexual and reproductive health.
Another difficulty identified by Interviewee D (2003, pers. comm., 27 August) was that organizations like hers lacked adequate funding both to run programs as well as to support PLWHA. She stated that because most PLWHA in China are rural poor, education on lifestyle, proper diet and medication was in vain as ‘many [patients] can’t follow these instructions because they live in poor conditions in rural China, where their income is just enough to feed their families’. However, with better funding, HIV/AIDS prevention and treatment campaigns could help PLWHA with the costs of living and medications, making their lives better (Interviewee D 2003, pers. comm., 27 August). Interviewee F (2003, pers. comm., 9 September) also identified funding as a problem for HIV/AIDS prevention and treatment. She stated that sometimes her organization wanted to carry out pilot projects, but because they were given insufficient funding they were unable to run the projects. Clearly, without the funding to properly test pilot programmes or institute nation-wide campaigns, HIV/AIDS prevention in China will continue to be hindered.
On the other hand, the introduction of the ‘Four Frees and One Care’ policy in 2003 has seen a positive change in the government’s funding response to China’s AIDS epidemic. The ‘Four Frees’ provided by the policy include government funded schooling for AIDS orphans, drug therapy for PLWHA, prevention of MTCT and voluntary counseling and testing (VCT). The ‘One Care’ component refers to care and economic assistance for people afflicted with or affected by HIV/AIDS (Cao et al. 2006: 520). However, by the government’s own admission, the implementation of this policy has been uneven (National Center for AIDS/STD Prevention and Control 2006: ii), so while it is certainly a step in the right direction, it is not fully operational as it will require a great deal of cooperation between all levels of government and assistance by civil society before it can really meet its objectives. It should be acknowledged that China has been injecting more funds into HIV/AIDS prevention and treatment strategies since 2003. The 2009 update by UNAIDS and the World Health Organization reported that there had been a threefold increase in funding by China in the period between 2003 and 2006 demonstrating stronger commitment from the government (UNAIDS and WHO 2009).
tensions, and sometimes contradictions, between the goals of public policies and the methods of policy practice, such as the conflict between public security (law enforcement) policies relating to sex work and public health policies for the prevention of HIV/AIDS (2008: 185).
Furthermore, issues pertaining to commercial sex workers and IDUs, which were handled by the MPS, also did not involve input from the MOH. This is quite possibly the reason why HIV/AIDS prevention advocacy programs have still not been uniformly implemented in all rehabilitation centres for IDUs and sex workers.
Interviewees C and F both believed that education campaigns aimed at the general population could be a valuable way to disperse HIV/AIDS information. They stated that efforts like the Severe Acute Respiratory Syndrome (SARS) mass media education campaigns would be a major step in changing people’s beliefs about HIV/AIDS and increasing knowledge and public awareness of the virus and how it is transmitted. After the cessation of SARS, the Chinese government did shift its focus to HIV/AIDS, and education campaigns on HIV/AIDS have been undertaken. Therefore, unlike previous efforts, top leaders in government have demonstrated they are serious in their response to HIV/AIDS. While this signals a positive change, unfortunately the gender issues that contribute to HIV/AIDS vulnerability do not appear to be an integral component of these campaigns, so their overall effectiveness is doubtful. In addition, gender inclusive campaigns would also need to be supported with active steps at both the government and grassroots level to reverse the continuing unequal social, political and economic structures that disempowered Chinese women, which have been shown to heighten their vulnerability to HIV/AIDS. However, Beijing’s reluctance to support the development of an unrestrained civil society in China makes this unlikely.
In the United Nations report HIV/AIDS: China’s Titanic Peril (2002), China’s political system was identified as possibly the most sensitive obstacle to tackling HIV/AIDS in the PRC. This was because the central government has long appeared uncomfortable with the emergence of organizations that are independent of the government and especially the free flow of information that such organizations may facilitate (UNAIDS 2002: 69–82). Yet, while the central government may fear that the emergence of civil society could contribute to a breakdown in the Chinese Communist Party’s authority in China, civil society participation and the free flow of information are not only good governance when responding to HIV/AIDS epidemics, but international experience has proven them to be essential elements in a state’s response to HIV/AIDS. Therefore, until the central government is willing to allow greater autonomy among the various NGOs and INGOs operating in China, it is unlikely that the Chinese response to HIV/AIDS will make any real inroads in the prevention of HIV transmission – and even less so in terms of gender-specific issues such as the human insecurities that increase women’s vulnerability to HIV/AIDS.
When determining women’s vulnerability to HIV transmission, female human security, or more aptly their ‘insecurity’, is an important factor. The status of many women in China, and the privileged position accorded to Chinese men, strongly indicates that Chinese women face a heightened vulnerability to HIV transmission. While many of these vulnerabilities are similar to women elsewhere in the world and certainly are not unique to China, they attest to the interplay of the unequal status accorded many Chinese women due to their sex, their disempowered status within society, unequal gender-based power relations both within the domestic and public arenas, and the patriarchal norms and attitudes that influence all of the above. By overlooking the many social, cultural, economic and political factors that contribute to HIV/AIDS vulnerability and transmission of the virus, particularly those faced by women, China has a long way to go before Chinese women are protected from HIV transmission. Given that HIV/AIDS heightens human insecurity, the stage is set for Chinese women (and men) to face an insecure future if the Chinese government does not fully implement international best practice, meaning a gendered response, into its overall HIV/AIDS response.
The transmission of HIV through blood selling is relatively unique to China and has caused many of China’s rural poor to become HIV positive. It has also been a very sensitive issue for the Chinese government due to the role of the Henan Provincial Health Department in both Henan’s blood trade and the initial cover-up of the emerging HIV/AIDS epidemic there. For further reading, see Hayes (2005).
This is largely because the surface of vaginal mucosa is much bigger than penile mucosa. Furthermore, semen from an HIV infected male is usually higher in HIV concentrations than are the vaginal secretions from a HIV positive female. Also, if a woman has a reproductive tract infection (RTI) or a sexually transmitted infection (STI), her vaginal mucosa is changed and can become irritated, ulcerated or more prone to scratches, all of which result in the vagina becoming more vulnerable to HIV infection (UNAIDS 2002: 57).
All interviewees spoken to during fieldwork were employed in government or non-governmental organizations that were responsible for HIV/AIDS prevention and treatment. Furthermore, none of the interviewees wanted to be identified, nor did they want the identity of the organization in which they worked to identified. This was largely due to the continued sensitivity of HIV/AIDS in China, particularly when discussing the issue with international researchers or reporters. Thus, the interviews were conducted upon the agreement that the interviewees’ details would be kept confidential. It is for this reason that neither the interviewees, nor the organizations they worked for, have been identified in this chapter.
Women now make up approximately 50% of those infected with HIV/AIDS globally. HIV infection rates in many countries also reflect that more women than men have contracted HIV. For example, HIV infection rates in Sub-Saharan Africa reveal that 60% of PLWHA are women. In the Caribbean the figure has reached approximately 50%, and if it follows the patterns of Sub-Saharan Africa it can be expected that women infected with HIV/AIDS will soon outnumber men there also. In Asia, approximately 35% of PLWHA are women, a figure that has increased since 2000 when the percentage was 19% (UNAIDS and WHO 2009).
However, there was no indication of what ‘basic’ knowledge meant and whether a basic knowledge reflected accurate and appropriate knowledge on how HIV could be prevented.
The National Population and Family Planning Commission of China reports that 38.24% of Chinese women have undergone sterilization and 45.51% have IUDs (Zhao 2001).
Surveys conducted in Africa reveal that 60–80% of HIV positive women, who contracted HIV from sexual intercourse, reported that their only sexual partner was their husband. Another study, which was conducted in India, another region where HIV/AIDS is growing at an alarming rate, reveals that 91% of HIV positive women surveyed, who had contracted HIV from sexual intercourse, also reported that their only sexual partner was their husband (Feinstein and Prentice 2000: 22). These findings support the results of an earlier study conducted in 1989 which also found the majority of HIV positive women who had contracted HIV through heterosexual intercourse, had also contracted HIV/AIDS from their only sexual partner, their husband. The researchers in this instance concluded that often ‘condom use was more effective in preventing HIV infection than was limiting the number of partners’ (Berger and Vizgirda 1993: 62).
For further reading, see Jeffreys (2004).
Clinics that are not privately owned are often linked to a person’s work unit so their HIV+ status is sometimes leaked to colleagues and employers.
The author would like to thank Professor Donald McMillen, Dr Rosemary Roberts and an anonymous reviewer for their insightful comments and suggestions.
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