Exchange Sex Associated With Different Types of Sexual Risk

Sexual risk, prevention behaviors, and psychosocial and sexual health outcomes were found to be associated with exchange sex among people at risk of HIV, with those associations varying by the type of exchange sex, according to a study published in Archives of Sexual Behavior.

Exchange sex, or the exchange of sex for money, goods, or services, has been associated with sexual risk behaviors as well as poor quality-of-life outcomes. Different kinds of exchange sex have been found to carry different likelihoods of sexual risk behaviors and poor social and health outcomes. The aim of this study was to “assess the risk profiles of different types of exchange sex among non-injecting cisgender men and women who engage in heterosexual sex.”

The National HIV Behavioral Surveillance project was used for its data, due to having behavioral surveillance data for men who have sex with men, people who inject drugs, and cisgender men and women who are at increased risk of HIV. Data was collected from Atlanta, Georgia; Baltimore, Maryland; Memphis, Tennessee; New Orleans, Louisiana; Portland, Oregon; and Seattle, Washington, for the 2019 cycle.

Participants who were aged 18 to 60 years, identified as a cisgender man or woman, resided in the specified metropolitan area, were able to complete the survey in English or Spanish, reported sex with at least 1 partner in the past year, and reported an income below poverty level were eligible for the study. All participants completed a tablet/computer survey that collected data on demographics; social, economic, and behavioral vulnerability to HIV infection; and access to HIV testing, care, and prevention. Participants were excluded if they did not answer whether they had received anything of value in exchange for sex.

Participants were separated into 4 groups based on exchange sex in the past year: no exchange sex, formal sex work, noncommercial exchange sex for drugs or money, and noncommercial exchange sex for other goods and services. Participant characteristics, risk factors, and sexual risk behaviors were also identified.

The 2189 participants included in the study were mostly non-Hispanic Black (78% of cisgender men, 70% cisgender women). Most participants also identified as heterosexual (99% of men, 80% of women). About 75% of the participants had no more than high school education and about one-third each reported homelessness, noninjection drug use, and recent heavy episodic drinking.

No exchange sex was reported by 94% of cisgender men and 81% of cisgender women in the past year. The most common exchange sex was noncommercial exchange sex for drugs or money (4% cisgender men, 12% cisgender women). Formal exchange sex was reported in 1% of cisgender men and 5% of cisgender women and noncommercial exchange sex for goods and services was reported in 2% in both cisgender men and women.

Sexually transmitted infection

Type of exchange sex was found to be significantly associated with condomless sex, anal sex, and past year sexually transmitted infection (STI) testing. Men who reported sex work (adjusted risk ratio [aRR], 2.01; 95% CI, 1.40-2.89), exchange sex for drugs or money (aRR, 1.36; 95% CI, 1.03-1.79), and noncommercial exchange sex for goods and services (aRR, 1.62; 95% CI, 1.22-2.16) had a higher risk of condomless sex compared with men who reported no exchange sex. A similar association was found in cisgender women, as risk of condomless sex was higher in women who reported sex work (aRR, 2.15; 95% CI, 1.80-2.58), exchange sex for drugs or money (aRR, 1.98; 95% CI, 1.69-2.33), and noncommercial exchange sex for other goods and services (aRR, 1.55; 95% CI, 1.11-2.17) compared with women who reported no exchange sex.

Risks of a high distress score and sexual violence were higher in men who reported exchange sex for drugs or money (aRR, 1.66; 95% CI, 1.08-2.54 and aRR, 6.13; 95% CI, 2.70-13.89, respectively) compared with men who reported no exchange sex. Men who reported exchange sex were also more likely to report a bacterial STI diagnosis. Similar associations were found in women, who were more likely to report a high distress score and a bacterial STI diagnosis (aRR, 1.53; 95% CI, 1.20-1.95 and aRR, 2.04; 95% CI, 1.18-3.54, respectively) compared with women who reported no exchange sex. Women were also found to report more physical and sexual violence if they engaged in exchange sex.

There were some limitations to this study. Data were cross-sectional, which means causal relationships could not be determined. Data were also self-reported, which could lead to recall and social desirability bias. Risks were assessed between exchange sex and no-exchange sex but not between types of exchange sex. It is unknown if all sites met the assumptions necessary for weighted estimates and inference. The number of cisgender men who engaged in exchange sex was small.

The researchers concluded that “this study provides compelling evidence that different types of exchange sex are associated with different types of sexual risk and outcomes among noninjecting cisgender men and women who are at risk for HIV via heterosexual transmission.”

Reference

Lipira LE, Glick JL, German D, et al. Type of exchange sex and associated behaviors and outcomes among cisgender men and women at increased risk for HIV via heterosexual transmission in six U.S. metropolitan areas. Arch Sex Behav. Published online August 23, 2023. doi:10.1007/s10508-023-02663-x