Sexual health of adolescent girls and young women in Central Uganda: exploring perceived coercive aspects of transactional sex

Abstract

Adolescent girls and young women (AGYW) in Uganda are at risk of early sexual debut, unwanted pregnancy, violence, and disproportionally high HIV infection rates, driven in part by transactional sex. This paper examines the extent to which AGYW’s participation in transactional sex is perceived to be coerced. We conducted 19 focus group discussions and 44 in-depth interviews using semi-structured tools. Interviews were audio recorded, and transcribed verbatim. Data were analysed using a thematic analysis. While AGYW did not necessarily use the language of coercion, their narratives describe a number of coercive aspects in their relationships. First, coercion by force as a result of “de-toothing” a man (whereby they received money or resources but did not wish to provide sex as “obligated” under the implicit “terms” of the relationships). Second, they described the coercive role that receiving resources played in their decision to have sex in the face of men’s verbal insistence. Finally, they discussed having sex as a result of coercive economic circumstances including poverty, and because of peer pressure to uphold modern lifestyles. Support for income-generation activities, microfinance and social protection programmes may help reduce AGYW’s vulnerability to sexual coercion in transactional sex relationships. Targeting gender norms that contribute to unequal power dynamics and social expectations that obligate AGYW to provide sex in return for resources, critically assessing the meaning of consensual sex, and normative interventions building on parents’ efforts to ascertain the source of their daughters’ resources may also reduce AGYW’s vulnerability to coercion.

Résumé

En Ouganda, les adolescentes et les jeunes femmes courent le risque d’un début précoce des relations sexuelles, d’une grossesse non désirée, d’actes de violence et d’un taux d’infection par le VIH disproportionnellement élevé, en partie du fait des rapports sexuels transactionnels. Cet article examine dans quelle mesure la participation des adolescentes et des jeunes femmes aux rapports sexuels transactionnels est ressentie comme coercitive. Nous avons mené 19 discussions de groupe et 44 entretiens approfondis à l’aide d’outils semi-structurés. Les entretiens ont été enregistrés sur bande audio et retranscrits textuellement. Les données ont été traitées au moyen de l’analyse thématique. Si les adolescentes et les jeunes femmes ne parlaient pas nécessairement de coercition, leurs récits décrivaient un certain nombre d’aspects contraignants dans leurs relations. Premièrement, la coercition par la force pour avoir « plumé » un homme (c’est-à-dire qu’elles avaient reçu de l’argent ou des ressources, mais ne souhaitaient pas fournir les rapports sexuels « obligatoires » en vertu des « clauses » implicites de la relation). Deuxièmement, elles ont décrit le rôle coercitif que l’obtention de ressources jouait dans leur décision d’avoir des relations sexuelles face à l’insistance verbale des hommes. Enfin, elles ont parlé du fait d’avoir des rapports sexuels comme résultat de circonstances économiques contraignantes, comme la pauvreté, et des pressions des pairs leur enjoignant d’avoir un mode de vie moderne. Un soutien à la création d’activités rémunératrices et des programmes de microfinance ou de protection sociale peuvent aider à réduire la vulnérabilité des adolescentes et des jeunes femmes à la coercition sexuelle dans les relations sexuelles transactionnelles. Viser les normes de genre qui contribuent à une dynamique inégale du pouvoir et à des attentes sociales qui obligent les adolescentes et les jeunes femmes à fournir des rapports sexuels en échange de ressources, évaluer de manière critique la signification de rapports sexuels consensuels et des interventions normatives s’appuyant sur les efforts des parents pour vérifier la provenance des ressources de leurs filles sont autant de mesures également capables de réduire la vulnérabilité des adolescentes et des jeunes femmes à la coercition.

Resumen

Las adolescentes y mujeres jóvenes (AMJ) en Uganda corren riesgo de inicio sexual precoz, embarazo no deseado, violencia y tasas desproporcionadamente altas de infección por VIH, impulsadas en parte por sexo transaccional. Este artículo examina en qué medida la participación de las AMJ en sexo transaccional es percibida como coaccionada. Realizamos 19 discusiones en grupos focales y 44 entrevistas a profundidad con herramientas semiestructuradas. Las entrevistas fueron grabadas y transcritas palabra por palabra. Se realizó un análisis temático de los datos. Aunque las AMJ no necesariamente utilizan el lenguaje de coacción, sus narrativas describen varios aspectos coactivos en sus relaciones. En primer lugar, la coacción por la fuerza como resultado de no practicar “toothing” con un hombre (es decir, recibieron dinero o recursos pero no quisieron proporcionar sexo por “obligación” bajo los “términos” implícitos de las relaciones). En segundo lugar, describieron el papel coactivo que el hecho de recibir recursos desempeñó en su decisión de tener sexo ante la insistencia oral del hombre. Por último, hablaron sobre tener sexo como resultado de circunstancias económicas coactivas, como la pobreza, y debido a la presión de sus pares para que mantengan estilos de vida modernos. El apoyo de actividades generadoras de ingresos, microfinanza y programas de protección social podría ayudar a reducir la vulnerabilidad de las AMJ a la coacción sexual en relaciones de sexo transaccional. Otras medidas que podrían reducir la vulnerabilidad de las AMJ a la coacción son: eliminar las normas de género que contribuyen a la desigualdad en la dinámica de poder y las expectativas sociales que obligan a las AMJ a proporcionar sexo a cambio de recursos, evaluar de manera crítica el significado de sexo consensual, y aplicar intervenciones normativas aunadas a los esfuerzos de los padres por determinar de dónde provienen los recursos de sus hijas.

Keywords:

• sexual health
• adolescent girls and young women
• transactional sex
• coercion
• Uganda

Introduction

Sexual health, as defined by the World Health Organization, is “a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence”.¹ The importance of adolescent sexual health is widely recognised, including in the Sustainable Development Goals (SDGs), adopted in 2015.²

Young people in sub-Saharan Africa face a number of challenges that negatively impact on their sexual health. This is often in the context of reduced access to information and services,³ owing in part to limited availability of adolescent friendly health services.^4,5 These challenges include unplanned pregnancy, and HIV and other sexually transmitted infections (STIs).⁵ Globally, adolescent girls and young women (AGYW) aged 15–24 years have HIV infection rates twice as high as their male counterparts ^6–8 with estimates indicating that 31% of all new infections in sub-Saharan Africa are among AGYW.^6,7,9

Approximately 54.7% of Uganda’s population are below 18 years of age with female youth twice as likely not to go to school as their male counterparts.¹⁰ The median age of female sexual debut is 16.9 years.¹¹ With 25% of adolescent girls pregnant before the age of 20, Uganda has one of the highest teen pregnancy rates in sub-Saharan Africa,¹⁰ this in the context of high unmet contraceptive needs amongst women of reproductive age.⁵ In Uganda, 3% of girls aged 15–19 years are living with HIV, with prevalence more than doubling to 7.1% by 24 years of age.¹¹ AGYW in Uganda are considered a key population for HIV prevention and face challenges such as stigma and lack of confidentiality in accessing reproductive health services.^12,13 Given the increasing burden of infection among AGYW, reducing HIV incidence has become a key priority for the Government of Uganda and its development partners, including the PEPFAR-funded DREAMS initiative, which seeks to reduce HIV infection amongst AGYW.^6,14–16

A recent study among young people in slum areas in Kampala, Uganda indicated that 34.3% agreed that it was okay for a boy to force a girl to have sex if he had feelings for her and 73.3% affirmed that it was common for strangers and relatives to force young females to have sexual intercourse with them without consent.⁵ AGYW are also at risk of sexual coercion, which is defined as an “act of forcing (or attempting to force) another individual through violence, threats, verbal insistence, deception, cultural expectations or economic circumstances to engage in sexual behaviour against his or her will”.¹⁷ This definition reflects that coercion, like the drivers of transactional sex itself, can include both interpersonal and structural aspects.¹⁸

Sexual coercion has also been linked to other sexual behaviours that place women at increased risk of negative sexual health outcomes including unwanted pregnancy, HIV and STIs, early sexual initiation, multiple sexual partnerships and lack of contraception use.¹⁹ The role of coercion in transactional sex – a behaviour that places women at increased risk of negative sexual health outcomes – is unclear. Transactional sex is defined as non-marital, non-commercial sexual encounters or relationships primarily motivated by the implicit assumption that sex will be exchanged for material benefit or status.^18,20 It is the negative sexual health outcomes and unplanned pregnancies associated with transactional sex that jeopardise the health, wellbeing and future of AGYW and are thus of concern, particularly if participation in such relationships is coerced.

Like their counterparts across the world, young people in Uganda engage in sexual relationships for a number of reasons including feelings of love, desire, and need for companionship; desire for emotional support; alcohol consumption; and social pressure to be in a relationship.²¹ Such relationships, however, are also structured by an implicit set of assumptions about the appropriate roles of men and women. These expectations exist within the wider normative system that expects men to provide resources to women in exchange for sex and other gendered benefits including domestic and reproductive labour.²² As a result, some relationships assume an even more explicit transactional frame.

Known in the Central Region of Uganda as okwegatta okwa “mpa-nkuwe” (“give me, I give you sex”), transactional sex relationships have been documented in both urban and rural contexts with young people, mainly AGYW, reporting involvement in such relationships for reasons including to obtain financial or material support; in response to emotions, desires and feelings; or as a result of implicit or explicit pressure to access consumer products or achieve social status.^23–28 Some AGYW also strategically engage in sexual relationships with older men, often known as “sugar daddies” as a means of securing resources.^25,28,29 Indeed, some AGYW describe agentive decisions to pursue relationships with older men in preference to younger men for a variety of reasons including financial benefit (as older men are perceived to have more wealth), emotional support (as older men are often perceived to be kinder) and meeting social expectations to keep up with the consumption of peers.^30,31

Transactional sex is perpetuated by a number of structural drivers which can be conceptualised as social or environmental factors that affect individuals’ choices and behaviours:³² for example, the absence of condoms in a person’s local community restricts their ability to practice safer sex. Social structures shape people’s behaviour, agency, and preferences and are often underpinned by social norms,³³ which in turn direct transactional sex relationship dynamics. Transactional sex is also driven by AGYW’s need to overcome gendered economic disadvantages and deprivations that increase their vulnerability. This includes inequality in access to education and information, violence against women and girls, limited livelihood options and economic dependence on men.^34–36 Social factors include AGYW’s desire to compete for social status amongst peer groups. Within the context of globalisation, social status is increasingly associated with material consumption.^18,22 Furthermore, transactional sex is also driven by normative expectations of courtship, which remain highly gendered. Men are expected to demonstrate their interest and investment in a relationship through material provision^{8,18,22,29,37–40} and women are expected to provide sexual access in exchange for material support.^{6,8,9,27,29,37,40}

There is a limited exploration in the literature of AGYW’s views of the extent to which they feel coerced into entering transactional sex relationships or the role that any coercion has on their sexual health. This paper is part of the Learning Initiative on Norms Exploitation and ABUSE (LINEA) https://www.lshtm.ac.uk/research/centres-projects-groups/linea and the STRIVE Research Consortium http://strive.lshtm.ac.uk/ and seeks to address this knowledge gap by exploring the views of AGYWs and other community members on the extent to which AGYW’s participation in transactional sex relationships is perceived to be coerced. This paper reflects upon both perceived interpersonal and structural drivers of sexual coercion.

Table 1. Participant sampling

Gender and site	Participant age group	Kampala	Masaka	Total
Focus group discussions
Female	14+ in school	1	1	2
	14–17 out of school	1	1	2
	18–24 out of school	2	2	4
	Adult women (35+)	1	1	2
Male	14+ in school	1	1	2
	14–17 out of school	1	1	2
	18–24 out of school	1	1	2
	Adult men (35+)	1	1	2
	Sugar daddies	–	1	1
Total		9	10	19
Individual interviews
Female	14+ in school	2	2	4
	14–17 out of school	2	2	4
	18–24 out of school	4	2	6
	Adult women (35+)	4	4	8
Male	14+ in school	2	2	4
	14–17 out of school	2	2	4
	18–24 out of school	2	2	4
	Adult men (35+)	3	2	5
	Sugar daddies	3	2	5
Total		24	20	44

Methods

Study context

The study was conducted in two sites in Central Uganda. The urban site, in Kampala District, is a low-income community located approximately 5 km from Kampala’s central business district. In the absence of urban planning, the community has grown into a commercial, industrial and residential centre with poor infrastructure, and exposure to challenges including flooding, poor sanitation, and poor-quality housing. Informal sector, self-employment dominates, and poverty is prevalent. We worked with an NGO active in this community, the Uganda Youth Development Link (UYDEL), which provides services to vulnerable and hard-to-reach young people aged 10–24 years. Collaboration with UYDEL facilitated access to the community and the identification of young people to be interviewed. Masaka is located approximately 130 km southwest of Kampala. The majority livelihoods in the rural site are derived from agriculture, petty trade and fishing. Transport infrastructure is mainly through motorcycle taxis known as boda bodas. While most houses are constructed with fired brick and corrugated iron roofs, some are constructed from mud and wattle with either corrugated iron or thatched roofs.

Sampling and data collection

Data were collected through individual in-depth interviews (IDIs) and focus group discussions (FGDs) with a broad range of participants to capture a variety of perspectives on transactional sex from adolescent girls and boys and adult women and men (Table 1). In Kampala, young out-of-school girls and boys aged 14–17 years were sampled from UYDEL’s residential care centre, which provides young people with educational and vocational training and support. Young women aged 18–24 years were sampled from one of UYDEL’s community-based centres from which AGYW are provided with vocational training, for example in hairdressing, and health and sexual health training. A second FGD was conducted with young women from the community who were aged 18–24 years but had no involvement with UYDEL or their services. Male participants aged 18–24 years, adults (aged 35+), participants of the community-sampled female FGD and all participants from Masaka, were sampled through the local government structure. Members of the local council approached individuals in their community whom they knew were in the desired age bracket and made them aware that the study was taking place. Potential participants then met with field researchers and were given more information about what the study entailed and were formally invited to take part. In-school girls and boys were sampled from secondary schools. Sugar daddies were identified through existing research networks by community mobilisers (long-term residents who are well-known in their communities and, in the absence of formal addresses, often help to mobilise fellow community members for a variety of research and non-research purposes). Mobilisers approached adult men who were known or suspected by the community to have relationships with AGYW. Not all men who were approached agreed to be interviewed or accepted this characterisation of themselves. Three men declined or denied involvement with AGYW and may have been fearful of the potential legal consequences of admitting to “defilement” – having sex with a minor under the age of consent (18 years).

Two female and two male field researchers, with experience researching sensitive topics and interviewing young people, collected data through sex-matched interviews. Nineteen FGDs, with an average of nine participants in each group, and 44 IDIs were conducted and audio recorded in Luganda using a semi-structured tool. Topic guides were developed based on a review of the literature, objectives of the study and discussions with partners. Themes included: friendship, popularity and peer pressure; motivations for, and consequences of, transactional sex; normative views of transactional and age-disparate sex; perceptions on young people’s readiness for sex; sexual consent; and views on sexual exploitation. Following the piloting of the tools, no significant changes were made to the questions.

Participants aged 18 years or older provided written informed consent. Participants aged 14–17 years provided written informed assent. UYDEL provided in loco parentis consent for young people under their care. For other young people, parents provided written informed consent. Apart from a few sugar daddies, no individuals invited to participate declined. No parents actively declined for their children to participate although in-school children who did not return a signed parental consent form were ineligible to participate.

Analysis

Analysis commenced during data collection: regular full-team debriefs were used to discuss the data, reflect on emerging themes, explore potential new lines of enquiry, and evaluate any unexpected findings. Preliminary findings were also discussed with UYDEL in order to incorporate their impressions into the ongoing analysis. Completed interviews were transcribed verbatim into Luganda and translated into English.⁴¹ Constant comparison and deviant case analysis techniques⁴² complemented the thematic analysis of the data. Following the preliminary coding of a sample of transcripts, a provisional coding frame was developed assisted by NVIVO 10 analysis software.⁴³ This coding frame included themes that were identified a priori and themes that emerged from the data. Separate coding frames were developed for the FGD and IDI interviews and for each participant group. The coding frames were finalised when saturation was reached and no new codes or themes emerged from the data.⁴⁴ Coded data were read and analysed by the theme to explore references to coercion in participants’ narratives including discussion of force, verbal insistence, cultural expectations and economic circumstances with reference to transactional sex relationships. The findings were compared across the data.^45,46 Names used are pseudonyms.

Ethical considerations

Ethical approval was provided by the ethics committees of the London School of Hygiene and Tropical Medicine, the Uganda Virus Research Institute, and the Uganda National Council for Science and Technology. The study adhered to WHO guidelines for the safe and ethical data collection on violence against women⁴⁷ and UNICEF guidelines on ethical research with children⁴⁸ including having a referral system in place should any participant be determined to require support following participation in the study. All study participants (child and adult) were eligible for referral if they requested a referral or if a field researcher or member of research management thought they would benefit from one. UYDEL was the referral partner for the study. UYDEL is staffed by counsellors and social workers and is well connected within Uganda’s child protection system. UYDEL’s position and connections were available for onward referral to appropriate state agencies (e.g. police) or other civil society organisations. Only one participant was referred for support.

Results

Returning to the definition of sexual coercion as the “act of forcing (or attempting to force) another individual through violence, threats, verbal insistence, deception, cultural expectations or economic circumstances to engage in sexual behaviour against his or her will”,¹⁷ in the sections that follow we explore the extent to which these elements were present in AGYW’s discourses when talking about transactional sex. We first discuss interpersonal dynamics through which AGYW describe being influenced to enter transactional sex relationships by others, before discussing economic circumstances which, according to AGYW’s accounts, coerced their participation in transactional sex relationships as a means of navigating their unfavourable structural contexts.

Coercive interpersonal aspects of transactional sex relationships

AGYW described risks associated with transactional sex, including reputational harm, exposure to unwanted pregnancy, HIV and STIs, and sexual violence. Some of these risks were considered consequences of being in a relationship in general, rather than a particular hazard of transactional sex per se. For some, the nature of transactional sex exerted additional pressures that increased their exposure to these risks. Even with awareness of risks associated with transactional sex, some AGYW participated in such relationships and described ways in which some aspects of coercion influenced them to do so.

Sexual violence and gender norms/cultural expectations

In the context of transactional sex relationships, many young women described sexual violence as a means through which AGYW could be coerced into having sex through force. This was most often described as a risk associated with “de-toothing” men whereby “you eat his money without having sex with him” making it a particular risk associated with transactional sex:

“[By not providing sex] she is also still taking a risk. You might proudly say that I ate his things [accepted his money] and did not pay him [with sex], but then he finds you along the way and reminds you of his things and even if you try to escape, there is no way out, he may not be alone…and they rape you. He can even end up infecting you [with HIV].” (KaF11-18-year-old young woman, in-school, Kampala)

Though this could not be considered consensual sex, one participant described however that the receipt of gifts could be a reason to “forgive” a man who forced her to have sex:

“He might have been giving you gifts and yet he doesn’t ask you for sex in return so if it happens accidentally and he forces you to do it, you don’t do anything about it … you feel bad but afterwards you forgive him.” (KaF3-FGD young women aged 18-24, Kampala)

A few participants also suggested that men’s expectation to receive sex in return for provision extended beyond the relationship dyad to include other men who were at times described as complicit in ensuring that girls “upheld their end of the bargain”:

“Even if you have gone to a discotheque there are some bouncers who plan with the men that take us out, if you drink his beer and he drags you out, even if you fight, the bouncer simply says that let him have you, you liked drinking his beer.” (KaF3-FGD young women aged 18-24, Kampala)

A few AGYW also noted how they could also be deprived of their ability to consent to sex through the use of alcohol:

“They buy us alcohol even when we are not in the mood of having sex with them, they buy us alcohol and we become drunk then they force themselves on to us because we are not a good state of the mind.” (Ka3 FGD young women aged 18-24, Kampala)

Verbal insistence

In the context of receiving resources, some AGYW described being coerced into having sex which, in the absence of these resources, they would otherwise not have had. Indeed, some AGYW described the coercive role that receiving things from men played in their decision to have sex:

“Because you want so many things from him, so he has more power over you, and you are humble and whatever he says you have to agree, because once you refuse [to have sex], that will mean an end to your relationship. So if you are thinking of denying him anything, then you are supposed to stop seeing him otherwise as long as you still want to have a relationship with him, you are supposed to agree to everything that he tells you.” (KaF8-17-year-old girl out-of-school, Kampala)

Particularly for girls who believed that their acceptance of resources was an implicit acceptance of their obligation to provide sex, there was a sense that a woman did not then have a right to change her mind about sex as she was expected to “uphold her end of the bargain”.

“It is also not fair, you must also know that as you are eating his things [receiving money or resources], time for pay back will come … Do not receive his things, if you know that you will not pay him back [with sex] in return.” (KaF12 18-year-old young woman in-school, Kampala)

Many AGYW who held this view also described being unable to refuse for fear of giving the wrong impression about their acceptance of a man’s resources. As such, their “agreement” to have sex could not be described as consensual:

“At times you do not want [to have sex] you want money and you know that he can only give you money if you have sex with him … and other times you do not want to show him that you do not love him … and in your mind you had not thought of having sex with him, for you, you only wanted to eat his money … so it happens and you do it, because you still want to get money from him … so you cannot refuse.” (Ma1 FGD in-school girls aged 14+, Masaka)

These circumstances were also reflected in the narratives of some adult men who had sex with AGYW and strategically used money and resources as a means of “winning” or coercing AGYW to have sex:

“… there is one I asked for sex for more than three years. Whenever I would travel I would bring her back charcoal and chicken. She had refused to sleep with me but one day I went to her place and ordered roasted pork for her. She also flagged down a hawker and asked me to buy knickers for her which I bought. Eventually she took me to her home and said that, “I wasn’t willing to sleep with you but because of the many things you have given me, I will do what you want”. So whenever you insist, and continue giving the gifts, you win.” (MaM13 -47-year-old man, Masaka)

Coercive structural aspects of transactional sex relationships

Economic circumstances

Particularly in Kampala, individual and household access to resources were contingent on access to money. The consequences of this were exacerbated by contextual factors that meant that residence in the community was fluid, reducing community cohesion and potential support from social network resources. This contrasted with Masaka where households were able to access some of their basic needs through subsistence farming. Amongst all participant groups, there was a perception that some men used money to coerce AGYW into sex. AGYW who were most susceptible to this coercion were often described as coming from poor, economically vulnerable households for whom even small amounts of money were attractive and coerced false agreement to sexual activity:

“In our community we have a man, he uses money … he tries his level best to make sure that he forcefully has sex with any girl that he is relating with … he lures them with money, when he gives this child money he starts talking with this child … you get to know that he only gave her very little money … That means that there are some men who force girls to have sex without their consent.” (KaF5 FGD adult women aged 35+, Kampala)

Although most parents believed that parents should be responsible for knowing where their children got resources, there was a perception amongst adults that some parents turned a blind eye to their daughters’ activities, particularly where there was an implicit expectation that daughters should contribute to the household. This was perceived to be a particular concern in households that were poor or food insecure – parents would ignore where or how children acquired money or food, given the household’s acute need for the resources that the girl supplied:

“Many parents, especially mothers, are focussing on their children to support the family … this has led to many problems. A mother might have a daughter who is 12 and she brings her food but the mother does not even care to ask where she got it. That is the most dangerous thing and it is something that is common in our [residential] zone.” (KaF5-35-year-old woman, Kampala)

Many AGYW also believed that with limited alternative livelihood or income-generation options, sexual relationships with men were, in effect, the reality for most in trying to meet their and their household’s needs.

“That is true, the living conditions are bad which forces girls to [have sex] … like me when I am at home and I know that we do not have what to eat, even my mother doesn’t have anything to provide for us, she is in her bed and when you talk to her she just shouts at you … So if I also pass by David and he says something to [propositions] me, I will not refuse because I know that he is going to give me 5000/= ($1.34) which will do a lot at home.” (KaF5 FGD with young women aged 18-24, Kampala)

Alternative income generating opportunities such as hairdressing or domestic work were often described by AGYW as insufficient, or insufficiently reliable, to meet their needs. This resulted in them resorting to sexual relationships with men, who in turn provided for basic household needs such as sugar or soap as well as consumer goods or money. Sexual relationships were thus a means for young women to navigate the structural constraints imposed by poverty, monetisation of the economy, and limited alternative livelihood options. Indeed a few young women noted that if they were able to work and support themselves, then they would no longer participate in sexual relationships to meet their needs, as a young woman from Masaka describes:

“[If girls had the money to provide for themselves] then they would reduce … it is because we cannot sustain ourselves, we cannot be independent that we decide to get boyfriends to support us. [If we had our own money] we would survive by ourselves, there is nothing that would put pressure on you [to have sex] because you can provide yourself with everything that you need.” (KaF10-20-year-old young woman, Masaka)

Some also linked reduced reliance on men to meet their economic needs as a means to reduce their exposure to other risks, for example, HIV infection:

“It is good [for girls to be able to afford all that they need] because then AIDS would not spread … many girls have HIV because they have had sex with men who have HIV.” (KaF10- 18-year-old young woman, out-of-school, Kampala)

While many AGYW accepted that they were unlikely to be their partner’s only sexual partner, several also acknowledged that exchange could complicate condom negotiation:

“… He tells you that the money is here, we don’t need to use a condom … so he confuses you and convinces you that he will be able to prevent you from getting pregnant … and you know most of us girls are more afraid of pregnancy than HIV so you have sex [without a condom] and end up contracting HIV.” (MaF1-17year old girl, in-school, Masaka)

This narrative captures the experience of other AGYW who did not have the skills or confidence to insist on condom use with their partners, reflecting the strong power difference between the AGYW and men involved in many transactional sex relationships. This difference was based on factors including the secrecy under which many transactional sex relationships were conducted, power imbalances imposed by age and experience, and vulnerability created by the need for economic support. A sugar daddy from Kampala describes:

“Remember, you are older than her and therefore you decide everything. That is the reason they often get pregnant because they do not determine their fate. She cannot advise you or ask you to use a condom as it is for you to decide for her at that age.” (KaM18-28-year-old “sugar daddy”, Kampala)

Feeling unable to insist on condom use was not the experience of all young women, however:

“We just have to part ways … that is my policy, you cannot trick me into having sex without a condom … the minute he says that, we just end the relationship.” (MaF7-17 year old girl, in-school, Masaka)

In general, AGYW who were able to insist on condom use were more often still in school or training and described a more optimistic outlook for their future. While exposure to HIV and limited ability to negotiate for safer sex was not only a characteristic of the coercion exerted by economic circumstances, some AGYW noted that the receipt of the resources meant that they agreed to, or maintained relationships in which they otherwise would not have engaged.

Peer pressure

Many AGYW also described the coercive lure of obtaining material goods as a way to “keep up” with their peers as a means of maintaining valued social connections and relationships. They often characterised the sex through which they obtained these goods as consensual:

“That is not bad, because the girl likes fashionable clothes, sex is merely sex, you are going to have sex for about twenty minutes but you are going to put on the clothes for a long time. Even if you have a suitcase full of clothes, you can say that aah we had the sex and it ended.” (KaF3 – FGD, young women aged 18-24, Kampala)

While described as consensual, many also noted that their economic circumstances otherwise prevented them from being able to obtain these goods, and how having sex was thus a means for them to secure them and resulted in them having sex that they might otherwise not have had:

“Girls have a lot of desires … if someone comes with a phone you … get into temptations simply because you want one … when you get to school you want to make people believe that you are of a higher class [through possessing consumer goods]. That’s why you get into a relationship that you are not ready for.” (KaF1- 16-year-old girl, in-school, Kampala)

Having a boyfriend was thus often described as a means for AGYW to meet their needs:

“Sometimes it is because of the friends, when the friend goes to a man and comes back with something, she says that do you see what Peter has given to me, and then the friend goes to Joseph and comes back with other items. When she goes out for shopping you almost collapse [in awe because of the items that she has come back with] why then don’t you also try it out? When you go out to the bar; you also get a man; sometimes it [transactional sex relationships] is because of the friends that we have.” (KaF3 –FGD 18-24-year-old women, Kampala)

Discussion

Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having consensual, pleasurable and safe sexual experiences, free of coercion, discrimination and violence.¹ As described elsewhere, many AGYW who participate in transactional sex relationships may not describe their involvement to have been coerced, with many highlighting the motivations and benefits of entering such relationships.^30,31 Indeed, and particularly in contexts in which transactional sex is prevalent, condemning the practice as amoral or non-normative risks casting judgement on those who are involved, which in turn risks alienating people who could benefit from support to avoid the harmful aspects of such relationships.

Some participants in this study describe how their involvement in transactional sex relationships was as a result of factors they described as coercive or forced such as sexual and physical violence in part shaped by gender norms and cultural expectations, verbal insistence, or forced consent/false agreement to sexual activity driven by poor economic circumstances.⁴⁹ Furthermore, our findings suggest that many AGYW believed that by accepting gifts or money from a man, there was an implicit expectation that they would have to provide sex in return. Not doing so was known as “de-toothing”, a practice that heightened the risk that sex would be secured through force. There was also some suggestion in the data however that receipt of money or gifts may have resulted in some AGYW perceiving an “obligation” to provide sex. The phenomenon of “de-toothing” has been described in other contexts in Uganda and recognised as a risky behaviour in the context of transactional sex relationships.^27,29,50,51

Some AGYW also described the coercive role that receiving resources from men played in their decision to have sex. This made them susceptible to verbal insistence from men who persuaded them to have sex (that they otherwise would not have had) for fear of the relationship ending, and/or losing access to the resources he provided, suggesting that this consent was coerced. Strategic use of resources to secure access to sex was also described by some men who pursued AGYW with gifts or money.

Amongst all participant groups, there was a perception that some men coerced AGYW into sex using money. AGYW who were most susceptible to this coercion were often described as coming from poor, economically vulnerable households for whom even small amounts of money were attractive. This was particularly reflected in the narratives of AGYW who believed that with limited alternative income-generation options, sex with men was, in practice, the most realistic means for them and their households to meet their needs. This finding has also been evidenced in other parts of sub-Saharan Africa where transactional sex is prevalent.^34,35,52

Economic circumstances were also described to exert a coercive influence on some AGYW through their desire to compete for social status amongst peer groups. Within the context of globalisation, social status, friendship and self-esteem are increasingly associated with material consumption.^18,22 This was reflected in the narratives of many AGYW who ascribed their involvement in transactional sex relationships to the resources, including consumer products such as phones, clothes and make up as well as personal grooming, that they received as a result.

The findings of this study offer important implications for interventions to reduce the coercive aspects of transactional sex and to highlight the importance of consensual sex. Structural interventions, for example improving young women’s access to financial resources, would usefully provide young women with a means to access their needs without having to rely on relationships with men. This could be through support for income-generation activities, microfinance, and social protection programmes, including cash transfers.⁵³ The mixed results on structural interventions such as cash transfers, where some studies have reported positive impacts and others have not,^54,55 suggest, however, that for meaningful impact, interventions would also need to engage with the strong gender expectations around men’s role in provision and encourage a process of critical reflection amongst AGYW on issues including their right to pleasurable consensual sex, partner choice, the risks associated with keeping up with the consumption of peers and their current and future aspirations.

The findings of this study also support the potential of community-level interventions to target gender norms and expectations that contribute to unequal power dynamics in sexual relationships and social expectations that obligate AGYW to provide sex in return for resources.⁵⁶ This could be particularly valuable given strong normative expectations of male provision, where AGYW describe strong expectations for their partner to provide for them, even when they have access to other resources.⁵⁷ Another important avenue could be to recruit existing norms around parenting and parents’ perceived obligations to safeguard their daughters. This could build on parents’ existing efforts to ascertain the source of their daughters’ resources while also prompting recognition of the impact of expecting AGYW to contribute economically to the household in the absence of any income-generation opportunities. This would be enhanced by interventions that assist parents and families to support their children economically, particularly as parents’ inability to safeguard their daughters is often linked to their inability to provide for them. The role of expectations for girls and young women to contribute financially to their households, even in the absence of income generating opportunities, has also been observed to contribute to the sexual exploitation of young people in other settings,⁵⁶ highlighting the potential wide applicability of such interventions.

This study has strengths and limitations. By talking to a broad cross section of people in two sites in Central Uganda, we have been able to explore perceptions of the coercive aspects of transactional sex from a variety of individual and contextual perspectives. We recognise, however, that with such a diverse group of participants of different ages, contexts and data generation methods (FGDs and IDIs), assessing how widely the various aspects of coercion were expressed, was challenging. Indeed, this effort was complicated by the fact that not all FGD participants necessarily voiced agreement or disagreement with all comments made by other participants and not all participants experienced all the aspects of coercion discussed in this paper. We also recognise that although all researchers were experienced in conducting research on sensitive subjects and made considerable efforts to build trust and rapport, the findings of this study may be limited by the fact that participants were interviewed in a single session by someone who was a stranger. This may have reduced their willingness to discuss their personal experiences of behaviour that they may have perceived to be stigmatising. We also recognise that, on the contrary, being a stranger might have also encouraged others to talk more freely. Sampling from beneficiaries of UYDEL in Kampala may have introduced selection bias by including young people who may have been particularly vulnerable, given that they were no longer under parental or familial care. However, we were keen to include young people with varying circumstances in order to explore transactional sex from a variety of perspectives.

Acknowledgements

We are grateful to the Oak Foundation who, as part of the Learning Initiative on Norms Exploitation and Abuse (LINEA), funded the research upon which this paper draws. This work also draws on the work of the DFID-funded STRIVE Research Consortium. Neither the Oak Foundation nor DFID had a role in the study design, data collection procedures or analysis and interpretation of the findings or decisions to publish the results. The views expressed are those of the authors alone. We are also grateful to our partner organisation, the Uganda Youth Development Link (UYDEL) who facilitated and supported our access to some study communities and were also the referral partners for any young people who might have needed support. We would also like to thank the field researchers for their dedicated work to collect the data upon which this paper is based. We owe particular thanks to the participants in this study who were willing to share their views and experiences with the study team and without whom this study would not have been possible.

ORCID

Nambusi Kyegombe http://orcid.org/0000-0002-3986-0361

Rebecca Meiksin http://orcid.org/0000-0002-5096-8576

Ana Maria Buller http://orcid.org/0000-0002-3007-9747

Additional information

Funding

This work was supported by Oak Foundation.