Trading in sexual currency: Transactional sex, sexual coercion and sexual behaviours among young people in Uganda

Abstract

The growing incidence and prevalence of sexually transmitted infections among young people, particularly HIV, is a public health concern in Uganda. There is increasing evidence that Ugandan youth engage in risky sexual behaviors, transactional sex, and experience sexual coercion. Most research on sexual behaviors has been limited to inter- and intra-personal factors that influence sexual behaviors. Prior research on transactional sex has often concentrated only on young girls, their motivations for receiving gifts, money, or favors in exchange for sex along with unsafe sex and sexual coercion due to power differential in such relationships. The general aim of this thesis was to gain a detailed understanding of the range of ecological factors that influence HIV-related sexual risk behaviors among the youth in Uganda, with a special focus on transactional sex. The findings of this thesis can help inform evidence-based interventions that are locally relevant and culturally adaptable in order to prevent the spread of HIV among Ugandan youth. The thesis is based on a mixed-method approach that includes quantitative cross-sectional and qualitative studies. Data was obtained from a questionnaire study conducted in 2010 among university students in Uganda (Studies 1 and 2); qualitative focus group discussions with students at a Ugandan university in 2014 (Study 3); and a nationally representative population-based survey of HIV sero-status carried out in 2011 (Study 4). Logistic regression was used as the main tool for analysis in the cross-sectional studies, while grounded theory was used for analysis of qualitative data. Study 1 revealed that alcohol consumption in relation to sexual activity was associated with such risky sexual behaviors such as multiple sexual relationships and inconsistent condom use with new partners. The findings of Study 2 show that sexual coercion, physical violence, and mental health were associated to a statistically significant degree with transactional sex among university students in Uganda. The qualitative findings showed that macrosystems such as cultural sexual scripts, gendered sexual scripts, poverty, and globalization influence the contexts in which young people engage in sex, not excluding transactional sex among university students. Finally, Study 4 revealed that among young women, receiving something for sex, and among young men, paying something for sex was associated with multiple concurrent relationships. Moreover, HIV positive sero-status was significantly associated with paying for sex among young men. The findings of this thesis suggest that there is need for HIV interventions, which address the multiple factors that influence sexual behaviors and transactional sex. Both sexes are equally vulnerable to sexual coercion and HIV risks associated with transactional sex, and therefore both should be targeted in intervention programs. A nuanced and flexible approach is needed. Young people should be actively engaged in the design and implementation of interventions that incorporate gender transformative approaches by critically challenging the implicit assumptions about traditional gender norms and socio-cultural factors that promote and facilitate sexual risk behaviors and transactional sex.

Abstract (Swedish)

Popular Abstract in English

Uganda is one of the youngest nations in the world. Majority of youth in Uganda are growing up in rapidly urbanizing and globalized environments that are characterized by changing social controls and breakdown of traditional norms. However, the youth still continue to face widespread poverty, high levels of unemployment, and have limited access to educational opportunities. These factors may have far reaching consequences for the health and well being of the youth in Uganda. Research indicates that sexual and reproductive health and rights issues are of public health concern among Ugandan youth.

The age of puberty is decreasing and age of marriage is increasing which suggests that there is increasing premarital sexual activity among youth. Often, this sexual activity happens in contexts of limited access to comprehensive sexuality education, forced or coerced sexual initiations and risky behaviors such as multiple and concurrent sexual partners, and little or no condom use. Hence, it is not surprising that youth in Uganda suffer from poor sexual and reproductive health outcomes like unwanted pregnancies, unsafe abortions, sexually transmitted infections including HIV epidemic. The last national level survey in Uganda reported a slight increase in HIV among Ugandan youth, with young women in Uganda having disproportionately higher rates of HIV infection. Economic inequalities, gender roles, and socio-cultural construction of masculinity and feminity are added factors that have been implicated as possible drivers of HIV epidemic among young women. Exchange of gifts, favors and money in return for sexual activity, particularly among young girls receiving something in exchange for sex from older men, and referred to as transactional sexual relationship is also considered to facilitate HIV transmission.

Prior research has often focused on intra and interpersonal factors that influence risky sexual behaviors including transactional sex among Ugandan youth. Moreover, there are knowledge gaps in research regarding the socio- cultural influence and contexts within which young people engage in transactional sex among other sexual behaviors. Also, traditionally research and interventions to prevent risky sexual behaviors including transactional sex have often focused on women, and them receiving something in exchange for sex. The present thesis aims to fill this knowledge gap and gain a deeper understanding of the factors that influence sexual activity, particularly transactional sex, among youth aged 15–24 years in Uganda. The thesis aims to create evidence that could inform public health programs and policies for decrease in behavioral risks of HIV transmission. The thesis comprised of research done among both young men and young women in general population and the ones going to universities in Uganda. The thesis includes statistical analysis of survey results from different data sources and analysis of focus group discussions held with youth going to a Ugandan university.

The findings of the thesis point to a significant amount of sexual coercion and transactional sex existing among youth in Uganda. Alcohol, particularly when consumed in relation to sexual activity, was found to be associated with risky sexual behaviors such as limited use of condoms with new partners and having multiple sexual partners. Sexual coercion and physical violence were also associated with receiving or providing something in exchange for sex for both sexes studying at universities. Also, the findings of the thesis point to the role of growing globalization and consumerism among university students that influences the use of sexuality as a commodity for exchange, particularly among young girls in university. However, these youth still grow up in a patriarchal society where there is widespread economic and gender disparity in favor of men and cultural practices like bride wealth for marriage that can be linked to contemporary practice of transactional sex among youth. Hence in such a situation, some young women may participate in transactional sex by will or be forced into it due to socio-economic situation, but both of them have limited ability to negotiate safe sexual activity with the partner who is providing something in return for sex. The findings also point that transactional sex among youth in general is related with having multiple sexual partners that overlap with each other in time. This may create a sexual network of youth and put them at risk for HIV transmission as these networks often include young people with transactional partners that are older and HIV positive. Young men who paid something in return for sex were also found to have higher risk of being HIV positive.

It is clear from the thesis that HIV interventions among youth in Uganda need to take into account multiple levels of individual, community, societal, and cultural factors that influence risky sexual behaviors and transactional sex. Treatment and counseling for both young men and young women with experience of sexual coercion is necessary as a part of public health interventions that are aimed at reducing sexual coercion and transactional sex. Programs aimed at promoting education, awareness and methods to negotiate safe sexual behaviors through comprehensive sexuality education are important. The interventions like conditional cash transfers aimed at promoting primary and secondary education and reducing school drop outs along with creating employment and income generating opportunities through skills development programs would also be beneficial in reducing unsafe sexual activity and transactional sex. Finally, the youth should be actively engaged to design and implement interventions that incorporate gender transformative approach through critically challenging the implicit assumptions about traditional gender norms and socio-cultural factors that promote and facilitate risky sexual behaviors and transactional sex and put them at grave risks.

• author: Choudhry, Vikas
• supervisor: Anette Agardh; Per-Olof Östergren
• opponent: Professor Okong, Pius, Uganda Christian University, Kampala, Uganda
• organization: Social Medicine and Global Health (research group); Social Medicine and Global Health-lup-obsolete (research group)
• publishing date: 2015
• type: Thesis
• publication status: published
• subject: Clinical Medicine
• keywords: Uganda, youth, university, transactional sex, alcohol, risky sexual behaviors, sexual coercion, gender norms, sexual scripts, globalization, bio-ecological systems
• in: Lund University Faculty of Medicine Doctoral Dissertation Series
• volume: 2015:34
• pages: 102 pages
• defense location: Aulan, Clinical Research Centre, Jan Waldenströms gata 35, Skånes universitetssjukhus i Malmö
• defense date: 2015-04-17 09:00:00
• ISSN: 1652-8220
• ISBN: 978-91-7619-113-2
• language: English
• LU publication?: yes
• id: 37f55a7a-dd79-4bd7-8b53-86602a80d53f (old id 5156440)
• date added to LUP: 2016-04-01 14:36:02
• date last changed: 2019-05-22 01:21:16