Sex tourism among Chinese men who have sex with men: a cross-sectional observational study

Local stigma associated with men who have sex with men (MSM) in low and middle-income countries is widespread. [1] Formal and informal condemnation of MSM in these settings encourage many men to hide their sexual orientation, especially in their hometowns. [2] This social pressure may contribute to an increase in sex tourism. [3] In this study, we define sex tourism as having traveled outside of one’s hometown to purchase sex in exchange for money or gifts.

Sex tourism may be important for HIV control for three reasons. First, this human movement could connect areas of low HIV prevalence and areas of high HIV prevalence. [4] The movement of high-risk individuals across areas with markedly different HIV prevalence has been shown to drive HIV transmission. [5, 6] Second, as sex tourists are a subgroup of clients of male sex workers, they often have greater power in deciding about condom use. [6] Third, traveling for sex is linked with unprotected anal intercourse and other behaviors that increase HIV risk. [7‐10]

While the literature on sex tourism has traditionally focused on men traveling in search of women, the topic of MSM sex tourism has recently become more common. [11] In addition, sex tourists were previously more common from high-income countries traveling to lower-income countries, but sex tourism originating from low and middle-income countries is increasingly common. China presents a strong location to study sex tourism among online MSM because of a growing number of domestic and international tourists [12] and a culturally repressed MSM society that is subject to numerous societal pressures to stay closeted. [4]

The purpose of this study was to characterize sex tourism in the context of Chinese MSM at high risk for HIV infection. We conducted an online survey to determine socio-demographic and behavioral correlates of MSM sex tourism in China.

In total, 7892 people clicked on the banner link to enter the survey, and 7551 (96%) started the survey. Of the 1597 participants who passed the exclusion criteria and agreed to the online informed consent, 1189 participants completed the survey. The majority of study participants were under 30 years old (82%), had never been married (83%), identified as gay (70%), had been educated beyond high school (68%), with an average income of less than $10,000 United States Dollars (USD) annually (82%). Full statistics of the study population are reported in Table 1.

We identified a subset of MSM sex tourists with multiple high-risk sexual behaviors. Most MSM sex tourist research has focused on high-income countries [7, 10, 17] or specifically recruited participants who have traveled recently. [7, 8, 10, 22] Our study extends the literature on sex tourism by including data in a middle-income country, comparing origin and destination HIV prevalence, and comparing the differences between those traveling primarily to purchase sex and those traveling primarily for other reasons.

We found that MSM sex tourists represented a broader group than that recognized by the World Tourism Organization, a subsidiary of the United Nations. This organization defines sex tourism as “trips organized … using [tourism] networks …with the primary purpose of effecting a commercial sexual relationship by the tourist with residents at the destination.” [23] This operational definition has been used in previous research. [10, 22] Our data suggest that in China, this definition is no longer adequate and that many MSM sex tourists will travel for primary reasons other than purchasing commercial sex. In fact, nearly two-thirds of our sex tourists would not be captured using this original definition. Comparison of the primary sex tourists who fall within the original definition and the non-primary sex tourists who do not shows that there is no significant difference in socio-demographic and sexual behavior characteristics, suggesting a broader definition is more appropriate. In addition, both primary and non-primary sex tourists reported their primary motivation to purchase sex while traveling was due to fear of recognition at home as well as a desire to try sex with males. This supports previous findings that Chinese MSM are driven to participate in sex tourism because of the strong social stigmas and bias against MSM. [24] A previous study has also argued for the need to include non-primary sex tourists in sex tourism research, and reported that sexual services are often purchased by those businessmen and others staying long-term at their destination. [9] We further broadened the definition of sex tourism by including domestic journeys as well as international journeys. Had we not defined sex tourism to include domestic travel, 75% of our sex tourists would not have been identified. By using our broader definition of sex tourism, we were able to capture a wider spectrum of individuals engaging in the same risky sexual behaviors. Thus, our data also suggest that previous research likely underestimates the frequency of MSM sex tourism. [10, 22]

Sex tourists displayed several high-risk sexual behaviors such as condomless sex, sex while drunk, group sex, multiple sex partners and having been paid for sex. These findings are consistent with findings from China, [24], the United Kingdom, [7] Belgium, [10] the United States, [8] and Vietnam. [22] This suggests that sex tourism may contribute to the co-occurrence of risk and disease syndemics. [25] Our participants reported slightly higher rates of condom usage at home than when traveling (23% versus 34%, respectively), contrasting existing research showing that sex tourists are more likely to use condoms while traveling. [24] Unprotected sex while traveling, in combination with other correlated risk behaviors such as group sex, sex while using drugs, sex while drunk and multiple sex partners, amplifies disease transmission. [5] This trend is consistent with the higher burden of living with HIV noted among sex tourists in our sample. Efforts to reduce HIV/STI transmission risks while traveling may be effective in reducing disease spread upon return. Delivering information on disease transmission and prevention prior to departure has been shown to reduce STI risk in Dutch marines prior to Cambodian travel, American Peace Corps volunteers in Africa and Swiss airline workers. [9]

Another key finding of our study was that sex tourists tend to travel from locations with low MSM HIV prevalence areas to locations with high MSM HIV prevalence, consistent with previous research from China. [26] This is likely related to the higher known burden of HIV in urban areas, [20] to where domestic sex tourists tended to travel. This presents a concern for disease transmission when travelers return to their home regions with lower HIV prevalence. [6] Previous studies on sex tourism in China [27] and internationally [5] have shown a trend in travel from regions of lower HIV prevalence to higher HIV prevalence, leading to transmission upon return. However, given the large migrant population in China, it may be challenging to isolate disease transmission secondary to migration from sex tourism. Studies targeted towards better understanding disease transmission dynamics are needed to illuminate the impact of sex tourism on disease transmission in China. Furthermore, the lack of access to healthcare and the low retention in the HIV treatment cascade among both the migrant population and sex tourists is extremely concerning. [28]

Some limitations of our study should be noted. First, our participants were recruited for an online survey, and MSM recruited through the Internet in China are on average younger and better educated. [29] In addition, we only recruited high-risk men, and men who consistently used condoms were not captured in this analysis. However, we believe this selection makes our findings even more relevant to HIV transmission. Second, as the survey was a cross-sectional study, it impossible to infer causal relationships or to interpret baseline activity. Questions on sex tourism and sexual risk behaviors were asked without a specific time frame. As we gathered data on MSM HIV prevalence from recent sources, these numbers changed and we cannot confidently correlate that to the MSM HIV prevalence during the time period each individual was traveling. Third, the definitions and indicators used by each source may have varied from both each other and our own definitions. Fourth, the small number of sex tourists limited our ability to examine some associations. However, as our study was a cross-sectional, observational study, the small percentage we noted may be a better estimation of the frequency of sex tourism among MSM in China. Fifth, although our study collected information on the price paid for sexual activities, we did not ask about which sexual activities were purchased. The lacking of this information limited our ability to know the cost of sexual tourism of the participants. Finally, only 62 people indicated that they engaged in sexual tourism. This small size limited our ability to conduct additional sub-analyses.

While it is becoming increasingly clear that sex tourism poses an international public health risk, more studies on the topic are necessary. Targeted studies using phylogenetic research would give a better understanding disease transmission. Site-specific phylogenetic studies have been able to provide definitive evidence of HIV transmission between Singapore and Malaysia, [5] in turn helping to more accurately design and target interventions. Our behavioral data is consistent with phylogenetic research suggesting sexual mixing between Thai and Chinese MSM. [30] Similar studies looking at travel within China would shed more light on the disease transmission due to migration.

Interventions need to be set in place to prevent disease transmission as a result of sex tourism. Using procedures requiring few resources, it may be possible to identify sex tourists for more targeted intervention. Facilitating healthcare access for MSM and implementing policies requiring healthcare providers to ask about recent travels and relevant sexual history may identify cases that would otherwise go unnoticed. In addition, giving pre-departure education to travelers either in health settings such as clinics or travel websites would also better inform travelers. At destinations popular for sex tourism, promoting healthcare access in the form of travel clinics and public advertisements promoting sexual health may also mitigate disease transmission risks. As several of our participants reported smartphone app use to locate a sexual partner, use of smartphones to deliver interventions may be useful in the future to target sex tourists both pre- and post-departure.

Sex tourism occurs in several countries, and has long been associated with risky sexual behavior, [7‐10] presenting significant public health concerns. The stigma associated with MSM behaviors will likely persist in low- and middle-income countries, increasing the need for improved public health programs and research. Given existing syndemics among MSM and differential HIV prevalence in origin and destination locations, sex tourism could amplify regional MSM HIV epidemics.