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Assessing risk factors and health impacts across different forms of exchange sex among young women in informal settlements in South Africa: A cross-sectional study

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  • Stoebenau, Kirsten
  • Dunkle, Kristin
  • Willan, Samantha
  • Shai, Nwabisa
  • Gibbs, Andrew

Abstract

For women in South Africa, engaging in exchange sex, including transactional sex (TS), or sex work (SW), is associated with several shared poor health outcomes; yet the practices themselves differ in meaningful ways. SW is a form of commodity exchange, while TS is grounded in gendered relationship expectations of male provision and aspects of emotional intimacy. Additionally, exchange sex types could be imagined on a “continuum of instrumentality” from relationships that do not include material support; to those characterized, but not driven by support; to those primarily motivated by material support. We use cross-sectional data from 644 women ages 18-30 enrolled in a trial addressing intimate partner violence in urban KwaZulu-Natal, South Africa to assess whether these conceptualizations may also map onto different types or levels of risk. Using self-reports, we developed four exchange sex relationship categories corresponding to a continuum of instrumentality: no exchange-based relationship; TS with a main partner only; TS with a casual partner; and SW. Using tests of association and adjusted logistic regression models, we compared socio-economic and behavioural risk factors, and health outcomes across reported forms of exchange sex. We find little difference between women who report no exchange sex and those who report TS only with a main partner. By contrast, as compared to women not in exchange sex, women in casual TS and SW were poorer, and significantly more likely to report problematic alcohol use, past drug use, prior non-partner sexual violence, and PTSD; with aOR higher for women in SW for many outcomes. When comparing casual TS to SW, we find women in SW held more gender equitable attitudes and were more likely to report modern contraceptive use. We discuss the implications for distinguishing between TS and SW, and use of the continuum of instrumentality conceptualization for research and programming.

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  • Stoebenau, Kirsten & Dunkle, Kristin & Willan, Samantha & Shai, Nwabisa & Gibbs, Andrew, 2023. "Assessing risk factors and health impacts across different forms of exchange sex among young women in informal settlements in South Africa: A cross-sectional study," Social Science & Medicine, Elsevier, vol. 318(C).
    • Handle: RePEc:eee:socmed:v:318:y:2023:i:c:s0277953622009479
    DOI: 10.1016/j.socscimed.2022.115637
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    References listed on IDEAS

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    1. Dunkle, Kristin L. & Jewkes, Rachel K. & Brown, Heather C. & Gray, Glenda E. & McIntryre, James A. & Harlow, Siobán D., 2004. "Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection," Social Science & Medicine, Elsevier, vol. 59(8), pages 1581-1592, October.
    2. Stoebenau, K. & Hindin, M.J. & Nathanson, C.A. & Rakotoarison, P.G. & Razafintsalama, V., 2009. ""... but then he became my sipa": The implications of relationship fluidity for condom use among women sex workers in Antananarivo, Madagascar," American Journal of Public Health, American Public Health Association, vol. 99(5), pages 811-819.
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    4. Stoebenau, Kirsten, 2009. "Symbolic capital and health: The case of women's sex work in Antananarivo, Madagascar," Social Science & Medicine, Elsevier, vol. 68(11), pages 2045-2052, June.
    5. Jewkes, R. & Morrell, R., 2012. "Sexuality and the limits of agency among South African teenage women: Theorising femininities and their connections to HIV risk practises," Social Science & Medicine, Elsevier, vol. 74(11), pages 1729-1737.
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