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"Why should I put myself at risk for something that is useless?": Emic understandings of risky transactional sex in Swaziland

Fielding-Miller, Rebecca Kathleen (2015)
Dissertation (135 pages)
Committee Chair / Thesis Adviser: Dunkle, Kristin L
Committee Members: Cooper, Hannah ; Windle, Michael ; Hadley, Craig
Research Fields: Health Sciences, Public Health
Keywords: HIV/AIDS; transactional sex; cultural consensus analysis; hegemonic gender; mixed methods
Program: Laney Graduate School, Behavioral Sciences and Health Education
Permanent url: http://pid.emory.edu/ark:/25593/pg0gk

Abstract

Introduction: Transactional sex is a risk factor for HIV. Qualitative studies have described how transactional relationships manifest in sub-Saharan Africa. However, the standard definition - the exchange of gifts or money for sex as distinct from sex work - does not allow differentiation between motives It requires relationships to be classified as either economically motivated or not -- despite the fact that all relationships may have a degree of economic and sexual obligation -- and does not account for women's emic perspectives.

Methods: We used cultural consensus modeling to build an emic scale of transactional sex that reflects Swazi women's lived experiences of sexual-economic exchange, conducted qualitative interviews to build a theory describing how women navigate the social and physical risks of transactional sex, and then tested this theory using structural equation modeling.

Results: Women in Swaziland are aware of the risk of HIV and carefully navigate both the social and physical risks of transactional sex. They value receiving different types of items from their partner depending on their relationship model, but do not necessarily see these relationships as economically motivated. Male economic support within socially sanctioned relationships is considered normative and highly respectable, but support in non-socially sanctioned relationships is stigmatized and considered unacceptable. In a path analysis, relationship agency had a significant effect on the risk pathways between transactional sex and HIV. Higher social status was associated with receiving more goods from a partner, while being called a nasty name associated with mercenary sexuality reduced social status and constrained agency intensified HIV stigma.

Discussion: Rather than being a single relationship type, some element of transactional sex is inherent in nearly all relationships and can have positive or negative effects on women's social standing. Different types of transactional relationships carry different risks. Future research and interventions should focus on how to best support women as they navigate health risks and the social landscape while considering gendered economic dynamics. HIV prevention strategies must acknowledge women's need to preserve a relationship to maintain social and economic stability.

Table of Contents

Table of Contents -- Chapter 1: Introduction.................................................................................... 1 -- Social drivers of HIV........................................................................................................ 2 -- Transactional sex.............................................................................................................. 3 -- Motives.................................................................................................................................. 4 -- Measurement.......................................................................................................................... 5 -- Intervention approaches............................................................................................................. 6 -- Theoretical considerations............................................................................................. 7 -- Social ecological model.............................................................................................................. 7 -- Hegemonic gender.................................................................................................................... 8 -- Current study................................................................................................................... 10 -- Gaps in understanding............................................................................................................ 10 -- Methods and approach............................................................................................................ 11 -- Cultural consensus modeling.................................................................................................... 11 -- Study setting.......................................................................................................................... 13 -- Study aims............................................................................................................................ 14 -- References........................................................................................................................ 16 -- Chapter 2: Cultural consensus modeling to measure transactional sex in Swaziland: Scale building and validation................................................................................................................. 24 -- Introduction.................................................................................................................... 25 -- Methods........................................................................................................................... 28 -- Setting.................................................................................................................................. 28 -- Ethical considerations............................................................................................................. 28 -- Study design.......................................................................................................................... 28 -- What do women hope to get in exchange for sex?......................................................................... 29 -- How are items valued in exchange for sex?................................................................................. 29 -- Are there distinct transactional sex CCMs?.............................................................................. 30 -- How do transactional sex CCMs differ from one another qualitatively?.......................................... 30 -- How does participation in a CCM affect social status and condom use?.......................................... 30 -- Results.............................................................................................................................. 32 -- What do Swazi women hope to get in exchange for sex?................................................................ 32 -- Are there distinct CCMs that value items differently?................................................................. 32 -- How do CCMs differ demographically?..................................................................................... 33 -- How are items valued in exchange for sex?................................................................................. 33 -- How do transactional sex CCMs differ qualitatively?.................................................................. 33 -- How does participation in a CCM affect social status and condom use?.......................................... 34 -- Discussion........................................................................................................................ 36 -- Technical Appendix....................................................................................................... 39 -- Model Building Using Cultural Consensus Analysis, Multiple Regression Quadratic Assignment Procedures, and Exploratory Factor Analysis 39 -- Table 1: CCM groups and answer keys.................................................................................... 43 -- Table 2: IDI quotes............................................................................................................... 45 -- Table 3: ANC Survey Demographics....................................................................................... 46 -- Table 4: aOR of condom use at last sex and aRRR of social status by CCM consonance quartile. Validated against etic definition of transactional sex 47 -- Table 5: MRQAP................................................................................................................ 48 -- References....................................................................................................................... 49 -- Chapter 3: "She is doing the wrong things for the right reasons": Navigating hegemonic femininity and risk in sexual-economic relationships................................................ 53 -- Introduction.................................................................................................................... 54 -- Methods........................................................................................................................... 56 -- Setting.................................................................................................................................. 56 -- Study Design......................................................................................................................... 57 -- Participants.......................................................................................................................... 57 -- IDI Data collection................................................................................................................ 58 -- FGD Data collection............................................................................................................. 58 -- Analysis............................................................................................................................... 58 -- Ethical considerations............................................................................................................. 59 -- Results.............................................................................................................................. 60 -- Respectability and sexual reputations........................................................................................ 60 -- Relationship Models............................................................................................................... 62 -- Inkhosikati........................................................................................................................... 64 -- Aspirational relationships....................................................................................................... 67 -- University relationships.......................................................................................................... 70 -- Sugar daddies........................................................................................................................ 74 -- Discussion........................................................................................................................ 76 -- Table 1: Participant competence scores and demographics............................................................ 80 -- Table 2: Monogamy and condom use likelihood by relationship type............................................... 81 -- Figure 1: Relationship models by social acceptability across the life course...................................... 82 -- References....................................................................................................................... 83 -- Chapter 4: Constrained agency and HIV risk in transactional sex relationships 87 -- Introduction.................................................................................................................... 88 -- Methods........................................................................................................................... 90 -- Setting.................................................................................................................................. 90 -- Participants.......................................................................................................................... 91 -- Ethical considerations............................................................................................................. 91 -- Measures.............................................................................................................................. 92 -- Analysis............................................................................................................................... 95 -- Results.............................................................................................................................. 97 -- Sample................................................................................................................................. 97 -- Constrained agency measurement model..................................................................................... 98 -- Summary statistics................................................................................................................. 98 -- Path model............................................................................................................................ 99 -- Discussion...................................................................................................................... 100 -- Conclusion..................................................................................................................... 104 -- -- Table 1: Select measures...................................................................................................... 105 -- Table 2: Summary and bivariate data by group........................................................................ 106 -- Table 3: Transactional sex score by variable for full sample and groups....................................... 107 -- Figure 1: Path model............................................................................................................ 108 -- Table 4: Model fit and standardized path coefficients................................................................ 109 -- References...................................................................................................................... 110 -- Chapter 5: Overview and implications for future research and theory 114 -- Main findings................................................................................................................ 115 -- Value of blended emic and etic perspectives............................................................................. 115 -- Transactional sex as a scale, not a binary................................................................................ 116 -- Women actively manage their social and physical risks.............................................................. 117 -- Risk pathways differ depending on relationship circumstances..................................................... 118 -- Strengths and limitations............................................................................................. 119 -- Implications for theory................................................................................................ 120 -- Hegemonic masculinity and the social ecological model............................................................... 120 -- Southern theory.................................................................................................................... 121 -- Future research............................................................................................................. 122 -- Transactional sex as a scale.................................................................................................. 122 -- Gender and transactional sex................................................................................................ 123 -- Summary and contribution.......................................................................................... 123 -- References...................................................................................................................... 124 -- -- -- FIGURES AND TABLES -- Chapter 2 -- Table 1: CCM Answer Key -- Table 2: IDI quotes -- Table 3: ANC survey demographics -- Table 4: aOR of condom use at last sex and aRRR of social status by CCM consonance quartile. Validated against etic definition of transactional sex -- Table 5: MRQAP -- Chapter 3 -- Table 1: Participant competence scores and demographics -- Table 2: Monogamy and condom use likelihood by relationship type -- Figure 1: Relationship models by social acceptability across the lifecourse -- Chapter 4 -- Table 1: Select measures -- Table 2: Summary and bivariate data by group -- Table 3: Transactional sex score by variable for full sample and by group -- Figure 1: Path model -- Table 4: Model fit and standardized path coefficients --

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