Abstract
Background:
Involvement in transactional sex encompasses a spectrum of activities ranging from casual sex to continual professional exchange of sex for benefits. Transactional sex is driven by economic, structural, social, legal, and psychological vulnerability factors that are common among men who have sex with men (MSM) and could negatively impact the gains and mileage achieved in HIV/AIDS epidemic control. Hence, this study was conducted to assess the prevalence and drivers of transactional sex among the MSM population in Plateau State Northern Central Nigeria.
Methodology:
This was a cross-sectional study conducted among the MSM population between October 2021 and June 2022 using a quantitative data collection method. Respondent-driven sampling (RDS) was used to recruit participants into the study. SPSS version 22 was used for data analysis with crude and adjusted odds ratios as well as 95% confidence interval used as point and interval estimates with a P ≤ 0.05 considered statistically significant.
Results:
The mean age of the study participants was 26.7 ± 5.4 years with 203 (42.6%) being strictly homosexual and 273 (57.4%) bisexuals. The prevalence of self-reported engagement in transactional sex was 89.9%, which was found to be driven by lack of employment in jobs (adjusted odds ratio [AOR]: 1.4, 95% CI: 1.1-2.3), bisexual orientation (AOR: 2.7, 95% CI: 1.1-6.4), positive family history of same-sex engagement (AOR: 4.6, 95% CI: 1.8-11.6), and being married (AOR: 2.6, 95% CI: 1.1-8.1).
Conclusion:
This study found a higher prevalence of engagement in self-reported transactional sex being driven by lack of employment, bisexual orientation, and positive family history of same-sex engagement.
Keywords: Men who have sex with men, Nigeria, prevalence, transactional sex
INTRODUCTION
Transactional sex refers to the consensual exchange of sex between adults for money or material goods such as food, drugs accommodation, love, or any other benefit whether regularly or occasionally.[1,2] Involvement in transactional sex encompasses a spectrum of activities ranging from casual sex to continual professional exchange of sex for benefits.[3,4] Transactional sex has been documented to be driven by economical, structural, social, legal, and psychological vulnerability factors such as poverty, gender inequality, lack of education, peer pressure, low self-esteem, sexual exclusion, criminalization and need to satisfy sexual desires.[2,3,4] These vulnerability factors are a common place among men who have sex with men (MSM) and other key population with huge potentials of impacting negatively on the gains and mileage achieved in HIV/AIDS epidemic control.[2,3,4] These factors also have the abilities to undermine the capacity of such individuals to adopt or negotiate less risky behaviors, thereby putting them at an increased susceptibility to HIV infection.[5,6,7] Additionally, the MSM and other key population are at a greater risk of acquiring HIV and transmitting it to the general population because they serve as a bridge between their circle and the general population particularly in setting where a number of them are bisexual.[8] Empirical evidence has shown that men who exchange sex for benefits have a higher likelihood of engaging in unprotected anal sex than those who do not practice transactional sex, which further posit the susceptibility to HIV and other sexually transmitted infections (STIs).[9,10] The estimated prevalence of lifetime engagement in transactional sex among the MSM in developed countries ranges from 16 to 20% while little is documented in this regard in the resource constrained and culturally diverse settings like Nigeria.[11] It was against this backdrop that this study was conducted to determine the prevalence and drivers of engagement in transactional sex among the MSM population in Plateau State as a way of generating homegrown evidence and contributing to the body of knowledge.
METHODOLOGY
Study area
This study was conducted in Plateau State, North Central Nigeria, with a population of 3.2 million people.[12] There is a wellestablished MSM network in the state with viable and functional smaller units as well as a viable coordination system and key population structure.
Study design
This study was conducted between October 2021 and June 2022 using a cross-sectional design to determine the prevalence of transactional sex and its drivers among MSM affiliated with the key population network in the state.
Study population
The study population consisted of all MSM 18 years and above affiliated with the key population network in the state.
Sample size determination
The sample size for this study was estimated using the formula for a cross-sectional study.[13] n is the minimum sample size, Z is the standard normal deviate at a 95% confidence interval (1.96), q is the complementary probability (1 – p), d is the precision of the study set at 0.05, and p is the prevalence of transactional sex (29.2%) from a previous study[14] giving a minimum sample size of 317.
Sampling technique and procedure
Respondent-driven sampling (RDS) technique was used in this study to recruit consenting eligible members of the MSM community into the study.[2,12] RDS is a modified form of snowball sampling that offers several advantages for hard-to-reach populations. Eligible members of the MSM population were enrolled in the study through the identified MSM network coordinators who were well-regarded by their peers and revered within the networks. This process of enrolment of eligible respondents continued until a saturation point was reached, where all consenting eligible respondents had been sampled and no respondent was gotten for a 4-week period.
Inclusion and exclusion criteria
All MSM affiliated to the key population network in the state who were 18 years and above were eligible to participate in the study. Those who declined to consent to the study will be excluded.
Data collection instrument
An interviewer’s administration approach was employed for data collection using an adapted data collection instrument[15] administered by four MSM unit coordinators who had been trained on the study protocol including the questionnaire. Proper translation and back translation of the questionnaire to the Hausa Language were done by different persons competent and vast in language translation. The questionnaire was pretested among MSM in neighboring states. This allowed for the assessment of the face and content validity of the tool. Overall the Cronbach alpha reliability assessment of the questionnaire was done using SPSS software with a Cronbach alpha score of 0.83. Prior to the administration of the questionnaire, informed consent was elicited and documented from all the respondents with the assurance of confidentiality and anonymity of their responses provided.
Data analysis
Explanatory variables for this study were categorized as demographic characteristics of the respondents as well as sexual and lifestyle behaviors. The socio-demographic characteristics included age as at last birthday, marital status, religion, educational status, and paid employment status. Sexual and lifestyle were assessed as sexual orientation categorized as bisexual and homosexual, family type assessed as monogamous and polygamous, family history of same sex orientation was assessed as present if the respondents had seen or known any family member engaging in sex with another man, cigarrete smoking status as yes or no, alcohol use as yes or no, injection drug use assessed as yes or no, engagement in a paid job assessed as engaged and not engaged, type of MSM categorized as penetrative, receptive or both, use of condoms in the last anal sex assessed as yes or no. Furthermore, number of male sexual partners was categorized as one or two or more. The outcome measure in the study was self-reported engagement in transactional sexual practice within the last 6 months prior to the study, which was assessed as engaged or not engaged. Transactional sex was assessed as non-marital, non-commercial sexual relationships motivated by an implicit assumption that sex will be exchanged for material support or other benefits, for example, money.[16]
All the returned questionnaires were reviewed for completeness and thereafter serialized. Data analysis was carried out using SPSSS statistical software version 22. Descriptive statistical analysis was carried out on quantitative variables such age of the respondent, age at same sex sexual debut expressed with mean and standard deviation as the summary indices. Other explanatory variables such as age group, marital status, sexual orientation, family history of same-sex orientation, smoking, alcohol use, etc., were presented in a frequency table expressed in frequencies and percentages. The outcome variable expressed as engaged or not engaged in transactional sex was presented in frequency and percentage on the frequency table. A multivariable analysis approach was used to determine the predictors of engagement in transactional sex. All the explanatory variable were fed in the binary logistic regressions model single where crude odds ratios and 95% confidence intervals generated following which all the explanatory variables except alcohol and injection drug use that did not have sufficient controls were fed simultaneously into the multiple logistic regression model. Multicollinearity was assessed by using the variance inflation factor (VIF) and tolerance values of the independent variables through linear regression. Tolerance values of 0.10 and below and VIF values of 10 and above were taken as the presence of collinearity.[17] The tolerance values in the study ranged from 0.51 to 0.92 and VIF values ranged from 1.16 to 1.16, indicating no collinearity between the variables. Adjusted odds ratios and 95% confidence intervals were generated and used as point and interval estimates of the measure of the effect of the explanatory variables predicting the engagement in transactional sex respectively with each variable in the model adjusting for the other. A probability value of less than 0.05 was considered statistically significant.
Ethical consideration
Ethical approval was obtained from the Institutional Review Board of the Jos University Teaching Hospital before the commencement of the study (JUTH/DCS/IREC/127/XXXI/2585).
RESULTS
The mean age of the study participants was 26.7 ± 5.4 years with 263 (55.3%) being 27 years and below. Assessment of their marital status revealed that 271 (56.9%) were single while more than half (58.4%) had completed secondary education. Forty-six (9.7%) and 88 (18.5%) of the participants had primary and tertiary education as their highest levels of educational attainment respectively. Majority (84.5%) of the participants were not employed in any form of paid jobs [see Table 1].
Table 1.
Socio-demographic characteristics of the respondents
| Variable | Frequency (n=476) | Percentage |
|---|---|---|
| Age (years) | ||
| <27 | 263 | 55.3 |
| 28 and above | 213 | 44.7 |
| Mean (±SD) | 26.7 (± 5.4) | |
| Marital status | ||
| Single | 271 | 56.9 |
| Married | 205 | 43.1 |
| Religion | ||
| Christianity | 90 | 18.9 |
| Islam | 386 | 81.1 |
| Educational status | ||
| None | 64 | 13.4 |
| Primary | 46 | 9.7 |
| Secondary | 278 | 58.4 |
| Tertiary | 88 | 18.5 |
| Employed in paid job | ||
| Yes | 74 | 15.5 |
| No | 402 | 84.5 |
SD=Standard deviation
With regards to the sexual orientation of the participants, 203 (42.6%) were strictly homosexual while the remaining 273 (57.4%) were bisexuals. The mean age of same-sex sexual debut was 18.2 ± 3.2 years with 166 (34.9%) debuting sex with same-sex partners earlier than 18 years of age. Positive family history of same-sex sexual orientation was elicited among 231 (48.5%) while 93 (19.5%) and 136 (28.6%) were penetrative and receptive MSM respectively. HIV status of the participants was self-reported to be positive among 105 (22.1%) and engagement in transactional sex was reported by 428 (89.9%) of the participants in the study [see Table 2].
Table 2.
Sexual and lifestyle behaviors of the respondents
| Characteristics | Frequency (n=476) | Percentage |
|---|---|---|
| Sex orientation | ||
| Bisexual | 273 | 57.4 |
| Homosexual | 203 | 42.6 |
| Age at same-sex sexual debut (years) | ||
| ≤17 | 166 | 34.9 |
| 18 and above | 310 | 65.1 |
| Mean (±SD) | 18.2 (±3.2) | |
| Family history | ||
| Yes | 231 | 48.5 |
| No | 245 | 51.5 |
| Cigarrete smoking | ||
| Yes | 42 | 8.8 |
| No | 434 | 91.2 |
| Alcohol use | ||
| Yes | 12 | 2.5 |
| No | 464 | 97.5 |
| Injection drug use | ||
| Yes | 7 | 1.5 |
| No | 469 | 98.5 |
| Type of MSM | ||
| Penetrative | 93 | 19.5 |
| Receptive | 136 | 28.6 |
| Both | 247 | 51.9 |
| Number of male sexual partners | ||
| 1 | 120 | 25.2 |
| ≥2 | 356 | 74.8 |
| Condom use in the last anal sex | ||
| Yes | 455 | 95.6 |
| No | 21 | 4.4 |
| Self-reported HIV test status | ||
| Positive | 105 | 22.1 |
| Negative | 371 | 77.9 |
| Engagement in transactional sex | ||
| No | 48 | 10.1 |
| Yes | 428 | 89.9 |
At bivariate analysis level, not being employed in a paid job was found to be a predictor of engagement in transactional sex with its odd being about three times those who were employed in paid jobs (95% CI: 1.6–6.0). The odds of engaging in transactional sex among those with a family history of same sex engagement was found to be 2.5 times those with no family history (95% CI: 1.6-6.1). Those who smoked cigarrete had 3.8 times the odds of engaging in transactional sex compared to those who did not smoke cigarette (95% CI: 1.8-8.5). The odds of engagement in transactional sex among those who drank alcohol was found to be about 10 times that of those who did not drink alcohol (95% CI: 3.5-41.1). The odds of engagement in transactional sex among those who used condoms in the last anal sexual intercourse was about six times those who did not use condoms (95% CI: 2.4-16.0.). However, using the multivariable model, the odds of engaging in transactional sex for the married participants was found to be about 2.9 times (95% CI: 1.1-8.1) those who were single having adjusted for other factors in the model. With regards to employment status of the respondents, the odds of engagement in transactional sex among participants who had no paid employment was 1.4 times (95% CI: 1.1-2.3) those with paid employment having adjusted for all other factors in the model. Respondents who were bisexual were found to have about three times (95% CI: 1.1-6.4) the odds of practicing transactional sex when compared to those who were strictly homosexual when all other factors in the model have been controlled for. Also, in this adjusted model, participants with a positive family history of same sex sexual orientation had 4.6 times (95% CI: 1.8-11.6) the odds of being engaged in transactional sex compared to those with negative family history of such [see Table 3].
Table 3.
Multiple Logistic Regression of Predictors of engagement in transactional sex
| Yes (n=428) | No (n=48) | Crude OR [95%CI] | Adjusted OR [95%CI] | |
|---|---|---|---|---|
| Age (years) | ||||
| ≥28 | 231 (87.8) | 32 (12.2) | 1.7 [0.9—3.1] | 0.6 [0.3—1.4] |
| ≤27 (ref) | 197 (92.5) | 16 (7.5) | ||
| Marital status | ||||
| Married | 185 (90.2) | 20 (9.8) | 1.1 [0.6—2.0] | 2.9 [1.1—8.1]* |
| Single (ref) | 243 (89.6) | 28 (10.4) | ||
| Religion | ||||
| Islam | 348 (90.2) | 38 (9.8) | 1.1 [0.5—2.2] | 2.9 [0.8—10.4] |
| Christianity (ref) | 80 (89.9) | 10 (10.1) | ||
| Education status | ||||
| Primary | 42 (91.3) | 4 (8.7) | 1.5 [0.2—2.7] | 0.3 [0.1—1.6] |
| Secondary | 247 (88.8) | 31 (11.2) | 1.1 [0.3—2.0] | 0.4 [0.1—1.9] |
| Tertiary | 83 (94.3) | 5 (5.7) | 2.4 [0.4—5.7] | 0.4 [0.1—1.4] |
| None (ref) | 56 (87.5) | 8 (12.5) | ||
| Paid job | ||||
| No | 370 (90.0) | 32 (10.0) | 3.2 [1.6—6.0] | 1.4 [1.1—2.3]* |
| Yes (ref) | 58 (78.6) | 16 (21.1) | ||
| Sexual orientation | ||||
| Bisexual | 252 (92.3) | 21 (7.7) | 1.8 [0.9—3.3] | 2.7 [1.1—6.4]* |
| Homosexual (ref) | 176 (86.7) | 27 (13.3) | ||
| Age at same-sex sexual debut | ||||
| (years) | 146 (88.0) | 20 (12.0) | 0.7 [0.4—1.3] | 0.9 [0.4—2.0] |
| ≤ 17 | 282 (91.0) | 28 (9.0) | ||
| ≥18 (ref) | ||||
| Family history of same sex | ||||
| Yes | 217 (93.9) | 14 (6.1) | 2.5 [1.6—6.1] | 4.6 [1.8—11.6]* |
| No (ref) | 211 (86.1) | 34 (13.9) | ||
| Smoking | ||||
| No | 397 (91.5) | 37 (8.5) | 3.8 [1.8—8.5] | 0.3 [0.1—1.2] |
| Yes (ref) | 31 (73.2) | 11 (26.8) | ||
| Alcohol | ||||
| No | 422 (90.9) | 42 (9.1) | 10.1 [3.5, 41.1] | - |
| Yes (ref) | 6 (50.0) | 6 (50.0) | ||
| Injection drug use | - | |||
| No | 422 (90.0) | 47 (10.0) | 1.5 [0.2—12.6] | |
| Yes (ref) | 6 (85.7) | 1 (14.3) | ||
| Type of MSM | ||||
| Penetrative partner | 85 (91.4) | 8 (8.6) | 1.4 [0.7—3.0] | 1.5 [0.4—5.1] |
| Receptive partner | 124 (91.2) | 12 (8.8) | 1.3 [0.6—2.6] | 0.9 [0.4—2.3] |
| Both (ref) | 219 (88.7) | 28 (11.3) | ||
| Number of male partners | ||||
| 1 | 111 (92.5) | 9 (7.5) | 1.5 [0.6—3.2] | 1.2 [0.5—3.0] |
| ≥2 (ref) | 317 (89.0) | 39 (11.0) | ||
| Condom use in the last anal sex | ||||
| Yes | 415 (91.2) | 40 (8.8) | 6.3 [2.4—16.0] | 1.6 [0.3—8.7] |
| No (ref) | 13 (61.9) | 8 (38.1) | ||
| Self-reported HIV test status | ||||
| Negative | 334 (90.0) | 37 (10.0) | 1.1 [0.5—2.2] | 1.5 [0.6—3.8] |
| Positive (ref) | 94 (89.5) | 11 (10.5) |
OR=Odds ratio, aOR=Adjusted odds ratio, CL=Confidence interval, ref=reference category, * = statistically significant
DISCUSSION
This study found a higher prevalence of self-reported engagement in transactional sex though similar but higher than what was reported in other similar studies conducted in Nigeria, Ecuador, Thailand, and in a cohort in West African region among the MSM population.[18,19,20,21] These findings of high prevalence of engagement in transaction sex as reported by these studies is a pointer to the fact that sex is most likely seen as an enterprise for achieving economic empowerment and a soft means for improving livelihood among this group but not just for gratification sexual desires. Furthermore, other studies conducted in Brazil, the United States of America, Sweden, and France reported slightly lower rates of the practice of transactional sex as compared to those previously stated studies.[11,22,23,24] This brings to light that the practice of transactional sex is a common place among the MSM population but could also vary by region and economic viability of the countries. Countries with reported higher rates of practice of transactional sex could seemingly be inferred as resource constrained and economically less viable of which the practice of transactional sex may not be peculiar to the MSM population alone. The economic and political dispositions of some of these countries could further drive this MSM group into the closet making the exchange of sex for monetary or financial gains lucrative. The continuous practice of transactional sex among the MSM population without adequate sexual negotiation skills and consistent as well as correct use of condom could continue to serve as the pathway for transmission of new HIV infections and other STIs among the MSM as well as in the general population which may contribute to gradually reversing the gains achieved in HIV and STIs epidemic control.
Engagement in transactional sex was found to be driven by factors such as being married, lack of employment in paid jobs, bisexual orientation, and family history of same sex engagement. These drivers were found to be similar with those reported by other studies such as unemployment, homelessness, unstable housing, concurrent sexual partnership, poor income, age, low level of education, being unmarried, alcohol use, and inadequate family support.[2,11,14,21] Transacting sex for money or gifts appears to driven largely by poverty as alluded to by the finding of the study lack of paid employment. The need to eke out livelihood in an unfavorable economy where little or no support is available from the government could continue to tilt this group toward this act. The association between family history of same-sex engagement and the practice of transactional sex could also be attributable the fact that some of the respondents may have grown up observing family members engaging same sex relationship for financial and material gains, which could have modeled them to see it as the norm. The lack of societal and political acceptability of same sex involvement in some settings would continue to drive this group into the closet, thereby promoting pretence of compliance to societal expectations resulting in bisexual status as a cover up. Findings from a study on the association of same-sex criminalisation laws and national HIV policies with HIV testing in African MSM revealed that of the 44 sub-Saharan African countries examined, engagement in same-sex relationships was reported to legal in less than half of these countries while interventions targeted at the addressing the needs of the MSM population were partially captured in the national HIV policies of just about two-thirds of these countries.[25] As a follow-up, the aforementioned point on repressive policies and law regarding same-sex engagement, another study also revealed that more than two thirds of 54 African countries examined currently criminalize homosexuality.[26] It is imperative that the society accepts of the sexuality choices of people create a viable platform for dissemination of sexual and reproductive health information as well as providing the needed structures to support the unemployed and those below the poverty line as ways of forestalling the act of exchange of sex for money or gift in this group and the general population.
It important to state that self-reporting approach was employed for the assessment of engagement in transactional sex in the study which in itself could have led to under reporting as a limitation of this study. However, self-reporting still remains a veritable method of assessment sex related involvement as this information could only be volunteered by willing participants.
CONCLUSION
This study found a higher prevalence of engagement in transactional sex, which is driven by a lack of employment, bisexual orientation, and a positive family history of same-sex engagement.
Authors contributions
TA participated in the conceptualization and design the study, literature review, analysis and interpretation of results, drafting and revising the manuscript, and final approval prior to submission for publication. JD, PA, RU, and KU participated in the design of the study, literature review, analysis and interpretation of results, drafting and revising the manuscript, and final approval prior to submission for publication. OO, SW, OO AZ, and PK participated in the drafting and revising of the manuscript, and final approval prior to submission for publication. All authors agreed to be accountable for the content of the work.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43 TW010543. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Funding Statement
The study was solely funded by the authors.
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