Stoebenau Kirsten, Dunkle Kristin, Willan Samantha, Shai Nwabisa, Gibbs Andrew
University of Maryland School of Public Health, Department of Behavioral and Community Health, 4200 Valley Drive, College Park, MD, USA.
Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa.
Soc Sci Med. 2023 Feb;318:115637. doi: 10.1016/j.socscimed.2022.115637. Epub 2023 Jan 2.
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.
对于南非女性而言，从事交换性活动，包括交易性性行为（TS）或性工作（SW），都与一些共同的不良健康后果相关；然而这些行为本身在一些重要方面存在差异。性工作是一种商品交换形式，而交易性性行为则基于男性给予的性别化关系期望以及情感亲密的某些方面。此外，交换性活动类型可以在一个“工具性连续统”上进行设想，从不包括物质支持的关系；到以物质支持为特征但并非由其驱动的关系；再到主要由物质支持驱动的关系。我们使用了来自南非夸祖鲁 - 纳塔尔省城市地区一项针对亲密伴侣暴力的试验中644名年龄在18至30岁之间女性的横断面数据，以评估这些概念化是否也可能对应不同类型或风险水平。通过自我报告，我们开发了四个与工具性连续统相对应的交换性活动关系类别：无基于交换的关系；仅与主要伴侣进行的交易性性行为；与偶然伴侣进行的交易性性行为；以及性工作。通过关联测试和调整后的逻辑回归模型，我们比较了社会经济和行为风险因素以及不同报告形式的交换性活动中的健康结果。我们发现报告无交换性活动的女性与仅报告与主要伴侣进行交易性性行为的女性之间几乎没有差异。相比之下，与未从事交换性活动的女性相比，从事与偶然伴侣的交易性性行为和性工作的女性更贫困，并且更有可能报告有问题的饮酒行为、过去使用毒品、先前遭受非伴侣性暴力以及创伤后应激障碍（PTSD）；在许多结果方面，从事性工作的女性的调整后比值比（aOR）更高。当比较与偶然伴侣的交易性性行为和性工作时，我们发现从事性工作的女性持有更平等的性别态度，并且更有可能报告使用现代避孕方法。我们讨论了区分交易性性行为和性工作的意义，以及工具性连续统概念化在研究和规划中的应用。
