Spring/Summer 2014 Damien de Walque, William H. Dow, and Erick Gong
Transactional sex rises after shocks,suggesting that access to insurance or savings may have public health implications
How poor people in low-income countries respond to the myriad risks they face is a crucial question. Their risk-coping behaviors can have long-term adverse consequences for both human and health capital, which has implications for the persistence of poverty. Transactional sex, the exchange of money or gifts for sexual relations, is believed to be one means that women use to cope with risk; it also leads to greater exposure to sexually transmitted infections (STIs), including HIV. While prostitution and sugar daddy relationships (relationships between younger women and wealthier older men) are most commonly associated with transactional sex, these types of relationships have also been documented among a broader population, including older married women.
Two questions have arisen from the literature: What are the health implications of transactional sex? And what conditions lead women to enter the market for transactional sex? Because transactional sex is believed to be a leading contributor to the HIV/AIDS epidemic in Sub-Saharan Africa, answers to these questions are of both scientific and policy interest.
Documenting transactional sex is difficult. It involves accurate measures of both sexual behavior and transfers made from partners. Many of the leading studies focus on commercial sex workers, who are more comfortable discussing their sexual behavior; other women may be less forthcoming. In addition, while transfers between clients and sex workers are typically made at the time of the sexual act, for women who are not sex workers the timing of transfers may not correspond with the act. For example, women may have a sexual occurrence with a friend, but receive a transfer from this partner days or weeks later.
A recent paper by de Walque, Dow, and Gong uses a unique set of data that measure sexual behavior, STIs, and transfers in a sample of women who are not sex workers and are representative of women in rural Tanzania. The analysis is based on a panel of women in rural Tanzania involved in a conditional cash transfer study aimed at the prevention of HIV and STIs. Four rounds of data, spaced four months apart, were collected. At each round individuals were tested for four curable STIs (chlamydia, gonorrhea, trichomoniasis, and Mycoplasma genitalium), which are used as the main outcome of interest. Compared with self-reported sexual behaviors, these biomarkers have the advantage of not being subject to selfreporting bias.
The authors estimate a relationship between household-level negative shocks and sexual behavior incorporating individual and time fixed effects. They find that women experiencing a negative shock are 5 percentage points more likely to be infected with an STI. The magnitude of this increase is both significant and large, corresponding to a 36 percent increase in STI risk over a four-month period. In addition, they find suggestive evidence that this effect is stronger among unmarried women and those with the lowest socioeconomic status.
The relationship established between shocks and STIs does not necessarily mean that women are responding to shocks by engaging in transactional sex. For example, women experiencing shocks may be unable to afford medical treatment for STIs. They may also have compromised immune systems that make them more susceptible to STIs. In both cases it is possible that a woman’s likelihood of having an STI could increase even if her sexual activity remains unchanged.
The authors therefore present corroborating evidence using data on selfreported sexual behaviors. They find that women experiencing shocks are 12 percent more likely to have unprotected sex. In addition, for unmarried women, for whom the relationship betweenshocks and STIs is strongest, they find that shocks lead to an almost threefold increase in paid sex (sex in exchange for cash or gifts). Finally, using reported income data, the authors estimate that as income goes down the risk of STIs
goes up. For unmarried women, they also find that as income goes down paid sex goes up.
This work contributes to the large body of literature documenting the effects of negative shocks on health outcomes and the relationships between income and disease. The study also provides additional evidence that transactional sex is not limited to sex workers but may be seen as a common risk-coping mechanism for a much larger population. Understanding the circumstances in which transactional sex occurs and the scope of this behavior has important policy implications. If transactional sex is being used as a risk-coping mechanism, then providing women with access to formal insurance or savings may have important public health implications.
Damien de Walque, William H. Dow, and Erick Gong. 2014. “Coping with Risk: The Effects of Shocks on Reproductive Health and Transactional Sex in Rural Tanzania.” Policy Research Working Paper 6751, World Bank, Washington, DC.