The authors have declared that no competing interests exist.
Conceived and designed the experiments: VC POO AA. Performed the experiments: VC. Analyzed the data: VC POO AEA AA. Contributed reagents/materials/analysis tools: AA POO. Contributed to the writing of the manuscript: VC POO AEA EK AA.
This study sought to determine the prevalence of transactional sex among university students in Uganda and to assess the possible relationship between transactional sex and sexual coercion, physical violence, mental health, and alcohol use.
In 2010, 1954 undergraduate students at a Ugandan university responded to a self-administered questionnaire that assessed mental health, substance use, physical violence and sexual behaviors including sexual coercion and transactional sex. The prevalence of transactional sex was assessed and logistic regression analysis was performed to measure the associations between various risk factors and reporting transactional sex.
Approximately 25% of the study sample reported having taken part in transactional sex, with more women reporting having accepted money, gifts or some compensation for sex, while more men reporting having paid, given a gift or otherwise compensated for sex. Sexual coercion in men and women was significantly associated with having accepted money, gifts or some compensation for sex. Men who were victims of physical violence in the last 12 months had higher probability of having accepted money, gifts or some compensation for sex than other men. Women who were victims of sexual coercion reported greater likelihood of having paid, given a gift or otherwise compensated for sex. Respondents who had been victims of physical violence in last 12 months, engaged in heavy episodic drinking and had poor mental health status were more likely to have paid, given a gift or otherwise compensated for sex.
University students in Uganda are at high risk of transactional sex. Young men and women may be equally vulnerable to the risks and consequences of transactional sex and should be included in program initiatives to prevent transactional sex. The role of sexual coercion, physical violence, mental health, and alcohol use should be considered when designing interventions for countering transactional sex.
Transactional sex is defined as an exchange of money, favors or gifts in exchange for sexual relations
Transactional sex is a contributing factor to the HIV pandemic, particularly among young girls in sub-Saharan Africa
A study in four sub-Saharan African countries reported transactional sex to be a common practice among more than two-thirds of young women in Ghana, Malawi, and Uganda
Transactional sex among women has been linked to basic survival and subsistence needs
University authorities in Uganda have acknowledged the prevalence of transactional sex among university students and its role in HIV transmission among this sub-group of young people
The cross-sectional study was conducted at the Mbarara University of Science and Technology (MUST) in southwest Uganda in 2010. Ethical approval was granted by the Institutional Review Committee at MUST. The students were approached in classrooms and in student dormitories at MUST, orally informed about the purpose of the survey and were invited to participate. Participation in the survey was voluntary and anonymity was assured. The students who agreed to participate in the survey were required to sign a consent form on the front page of the questionnaire that also included the explanation and justification of the survey.
The survey took place in lecture halls at MUST, with a member of the research team present. Contact details for the principal investigator and a research assistant were also provided, in case any questions or personal concerns would arise while answering the questions. The consent forms and the questionnaires (without identifying information) were collected separately and placed in different boxes in the front of the rooms to maintain anonymity of the survey.
Of the 2706 undergraduate students invited to participate, 1954 gave their consent and completed the questionnaire (72% response rate). Our study was a follow-up to a survey conducted at MUST in 2005 using the same questionnaire
The statistical analysis was done using IBM–SPSS Version 20.0. Confidence intervals (CI) were calculated at the 95% level to estimate statistical significance. Descriptive analyses were stratified by sex. Differences in proportions were calculated using chi-square tests.
Bivariate logistic regressions were performed separately for men and women to calculate the crude odds ratios (OR) for the effect of various risk factors on engaging in selling sex and buying sex in exchange for money/gifts.
A step-wise multivariate logistic regression modeling was performed based on the contributions of various factors in bivariate analysis. Gender was adjusted for in the first step, followed by other study variables. All the factors were included in the final model to facilitate comparisons across reporting paying or accepting money, gifts or other form of compensation in return for sex. Effect modification was tested and interaction terms between being victim of physical violence in the last 12 months and gender, and sexual coercion and gender were included in the final multivariate logistic regression model. The results report sexual coercion and being victim of physical violence in the past 12 months by gender to account for the interactions.
Experience of sexual coercion was high (29%) in both sexes, although a significantly higher proportion of women (35.4%) reported having experienced some form of sexual coercion at some point of time in their lives. A greater proportion of women (54.5%) than men scored high on mental health scores, indicating poor mental health status. More men than women (23% vs. 18.5%) reported heavy episodic drinking (HED), while being victims of physical violence in last 12 months was similar among men (10.7%) and women (9.8%) (see
Variables | Categories | All (N = 1954)n (%) | Men (n = 1087)n (%) | Women (n = 867)n (%) | chi-square |
Age | <24 years | 1346 (71.7) | 708 (67.4) | 638 (77.2) | <0.001 |
≥24 years | 531 (28.3) | 343 (32.6) | 188 (22.8) | ||
Area of growing up | Urban | 1067 (55.1) | 551 (51.2) | 516 (60.9) | <0.001 |
Rural | 869 (44.9) | 526 (48.8) | 343 (39.9) | ||
Educational attainmentof parents | >primary school | 518 (27.3) | 329 (31.1) | 189 (22.5) | <0.001 |
≤primary school | 1382 (72.7) | 730 (68.9) | 652 (77.5) | ||
Missing | (54) | (28) | (26) | ||
Living arrangementswhile growing up | Both parents | 1020 (52.2) | 554 (51) | 466 (53.7) | .240 |
Single parent/others | 934 (47.8) | 533 (49.0) | 401 (46.3) | ||
Heavy episodicdrinking | No | 1547 (79.1) | 840 (77.2) | 707 (81.5) | <0.001 |
Yes | 205 (21.9) | 151 (22.8) | 54 (18.5) | ||
Missing | (202) | (96) | (106) | ||
Mental healthscore | Low (satisfactory) | 920 (50.4) | 549 (54.5) | 371 (45.5) | <0.001 |
High (poor) | 904 (49.6) | 459 (45.5) | 445 (54.5) | ||
Missing | (130) | (79) | (51) | ||
Social participation | High | 778 (39.8) | 454 (41.8) | 324 (37.4) | .051 |
Low | 1176 (60.2) | 635 (58.2) | 543 (62.6) | ||
Ever experienceof sexual coercion | No | 1143 (71.0) | 671 (76.3) | 472 (64.6) | <0.001 |
Yes | 467 (29.0) | 208 (23.7) | 259 (35.4) | ||
Missing | (344) | (208) | (136) | ||
Victim of physicalviolence in thepast 12 months | No | 1687 (89.7) | 930 (89.3) | 757 (90.2) | .542 |
Yes | 194 (10.3) | 112 (10.7) | 82 (9.8) | ||
Missing | (73) | (45) | (28) |
Sexual Behaviorvariable | Categories | All (N = 1954)n (%) | Men (n = 1087)n (%) | Women (n = 867)n (%) | chi-square |
Exchanging sex byproviding or receiving gifts,money or compensation | No | 897 (74.6) | 443 (70.0) | 454 (79.8) | <0.001 |
Yes | 305 (25.4) | 190 (30.0) | 115 (20.2) | ||
Missing | (752) | (454) | (298) | ||
Exchanging sex byproviding gifts, moneyor compensation | No | 1115 (85.1) | 534 (77.3) | 581 (93.9) | <0.001 |
Yes | 195 (14.9) | 157 (22.7) | 38.1 (6.1) | ||
Missing | (644) | (396) | (248) | ||
Exchanging sex byreceiving gifts, moneyor compensation | No | 1123 (87.5) | 597 (89.9) | 526 (84.8) | <0.001 |
Yes | 161 (12.5) | 67 (10.1) | 94 (15.2) | ||
Missing | (670) | (423) | (247) | ||
Exchanging sex by bothreceiving and providing gifts,money or compensation |
51 (4.2) | 34 (5.4) | 17 (3.0) | <0.001 |
A majority of men (77%) and women (79%) who reported having accepted money, gifts or some other form of compensation for sex, had done it more than once. Having an age disparate transactional partner was frequent among women (65%) with transactional partners more often being older men, while men mostly had same age transactional partners (65%). Almost all women (92%) who reported having accepted money, gifts or some other form of compensation for sex had a male partner while one-third of all men (n = 67) who reported the same behavior had transactional partners as men (data not shown).
Accepting gifts, moneyor compensation for sex(ORcrude, 95% CI) |
Paying money, givinggift or compensatingfor sex (ORcrude, 95% CI) |
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Characteristics | All | Men | Women | All | Men | Women |
Age≥24 years | 1.34(.94–1.92) | 1.06(.62–1.82) | ||||
Rural residencewhile growing up | 1.38(.99–1.92) | 1.10(.70–1.72) | 1.21(.90–1.65) | 1.10(.77–1.50) | 1.02(.53–2.00) | |
Educational attainmentof parents ≤primaryschool | 1.14(.80–1.64) | 1.32(.80–2.22) | 1.13(.67–1.90) | .94(.66–1.33) | .82(.55–1.21) | .63(.26–1.55) |
Heavy episodicdrinking | 1.37(.98–1.94) | 1.61(.95–2.73) | 1.40(.85–2.22) | 1.30(.65–2.60) | ||
Poor mentalhealth status | ||||||
Growing up withsingle parent or others | 1.32(.98–1.80) | 1.27(.90–1.83) | 1.53(.80–3.00) | |||
Low socialparticipation | 1.12(.80–1.60) | .98(.60–1.60) | 1.20(.75–1.90) | 1.20(.90–1.66) | 1.31(.93–1.90) | 1.58(.78–3.26) |
Victim of physicalviolence in thepast 12 months | ||||||
Ever experience ofsexual coercion |
*Crude Odds Ratio [ORcrude], 95% Confidence Intervals [CI].
Bold font indicates statistical significance at p<.05.
Accepting gifts, money or compensation for sex | Paying money, giving gift or compensatingfor sex | |||
Characteristics | ORadjusted | 95% CI | ORadjusted | 95% CI |
Female sex | ||||
Age≥24 years | 1.24 | .80–1.94 | ||
Rural residence whilegrowing up | 1.43 | .82–2.05 | 1.05 | .71–1.56 |
Educational attainmentof parents ≤primary school | .76 | .93–2.22 | ||
Heavy episodic drinking | 1.50 | .97–2.23 | ||
Poor mental health status | ||||
Growing up with singleparent or others | 1.35 | .89–2.05 | 1.26 | .87–1.84 |
Low social participation | .80 | .52–1.20 | ||
Victim of physical violenceover the past 12 months |
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Male (Ref- Male not a victimof physical violence) | ||||
Female (Ref.- Female not avictim of physical violence) | 1.20 | .59–2.50 | ||
Ever experience of sexualcoercion |
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Male (Ref- Male with no experienceof sexual coercion) | 1.53 | .98–2.40 | ||
Female (Ref.- Female with noexperience of sexual coercion) |
*Adjusted Odds ratio [ORadjusted], 95% Confidence Intervals (CI). All variables have been adjusted for each other.
Sex-specific ORs from interaction between victim of physical violence in last 12 months and sex of individual.
Sex-specific ORs from interaction between ever experience of sexual coercion and sex of individual.
Bold font indicates statistical significance at p<.05.
Being a male and older age (ORadjusted 1.94, CI 1.38–2.85) was significantly associated with experience in having paid or given a gift or otherwise compensated for sex. Also, being a victim of physical violence in the last 12 months for men (ORadjusted 2.25, CI 1.26–4.00) and women (ORadjusted 2.58 CI 1.09–6.14), poor mental health status (ORadjusted 2.09, CI 1.40–3.13), and heavy episodic drinking (ORadjusted 1.67, CI 1.14–2.44) were associated with experience in having paid or given a gift or otherwise compensated for sex. In the fully adjusted model low social participation was significantly associated with experience in having paid or given a gift or otherwise compensated for sex (ORadjusted 1.48, CI 1.01–2.17).
There is a high prevalence of transactional sex among Ugandan university students with gender playing an important role regarding the type of transaction. Accepting money, gifts or some other form of compensation in exchange for sex was more common among women, while men had a higher prevalence of paying or giving a gift or otherwise compensating in exchange for sex. Experience of sexual coercion for both men and women and being a victim of physical violence in men were both associated with having accepted money, gifts or some other form of compensation for sex. Heavy episodic drinking, poor mental health status, and being a victim of physical violence in last 12 months was associated with experience of having paid or given a gift or otherwise compensated for sex. In addition, women with experiences of sexual coercion had a higher likelihood of having paid or given a gift or otherwise compensated for sex in comparison to other women.
Our study found the prevalence of transactional sex to be 25.4%, much higher than shown in national surveys of Uganda
Being a woman, having poor mental health status, and experience of sexual coercion were significantly associated with reporting having accepted money, gifts or some other form of compensation for sex. Our results are congruent with findings from other studies in Africa including Uganda, which have found that women who have had coercive experiences were more likely to exchange sex for money and other material gifts
Studies from high-income countries in Scandinavia have shown that among adolescents, males reported accepting money, gifts or compensations for sex more often, which is contrary to our study findings
Our results indicate that men who have been victims of physical violence in the last 12 months were at higher risks of reporting having accepted money, gifts or some other form of compensation for sex compared to other men. A study in the same setting found that when both male and female students were exposed to violence at the university, this exposure was significantly associated with experiences of sexual coercion
Having experienced a coercive event of sexual or physical violence can impact the mental health of a young person of either sex
It appears that transactional sex may compound a great deal of HIV risk since, from sexual exchanges alone, experiencing physical, mental, or sexual abuse has been linked to a higher risk of HIV infection and poor sexual and reproductive health outcomes
Being a man and of older age was identified as being associated with higher probability of having paid or given a gift or otherwise compensated for sex. A possible reason why men report providing money or gifts in return for sexual relations may include prevailing masculinity norms namely, having a provider role in relationship where the notion of sexual entitlement is a central part of that role
A study done in Uganda found that men and women who had been exposed to threats of violence or subjected to physical violence were approximately twice as likely to experience sexual coercion
Young perpetrators or victims of violence have been shown to have high levels of alcohol and drug use, as well as increased likelihood of engaging in other behaviors which increase the risk of HIV transmission, including transactional sex
In the past decade, researchers have identified the possible synergistic co-occurrence of various epidemics and risk factors that contribute additively to increased risk of poor health outcomes, a phenomenon referred to as syndemic
The cross-sectional design of our study does not allow analysis of causal relationships between events. We acknowledge that while our study sample is highly selective and our findings may not be generally representative of other young people in Uganda, it is representative of Ugandan university population.
The data used in the study were obtained by retrospective self-reporting that could have resulted in recall bias. Although the survey we conducted was anonymous, the sensitive nature of the items, relating to sexual behavior may have affected the responses we received. Selection bias may exist due to the high rate of non-responses (38%). The prevalence of transactional sex and experiences of sexual coercion among students, particularly men, may have been higher than reported in the questionnaire, since these experiences may be considered socially undesirable to report. If this were so, it should bias the differences in the study sample towards the null. Our study did not include experiences of forced anal sex, which may have led to under reporting of sexual coercion, particularly among men having sex with men and in heterosexual relationships in order to prevent pregnancy.
Nonetheless, we believe the inclusion of young men and comparison of risk factors for selling and buying sex is a key strength of our work. Also, our study results could control for a number of potential confounders in assessing the true relationship between various risk factors and transactional sex.
The high prevalence of transactional sex necessitates a prevention program among university students. We have indicated that males and females who sell or buy sex have different susceptibility profiles. However, both sexes in Ugandan universities are equally vulnerable to the risks associated with transactional sex and therefore both need to be targeted in prevention programs. Policy and programmatic initiatives should also consider the potential role of transactional sex with regard to STIs including HIV risk. Attention must be given to, the possibly intertwined, roles of sexual coercion, physical violence, alcohol use, mental health, and social environmental factors in shaping sexual behaviors of young people. Treatment and counseling programs for youth who are victims of sexual coercion and physical violence are critical to decrease the risks associated with transactional sex, along with research on protective factors against involvement in transactional sex.