Abstract
The rise in opioid misuse coincides with increased sexually transmitted infection (STI) and HIV incidence. Transactional sex is an under-researched phenomenon among Black Americans who misuse opioids, and may increase their risk of STI or HIV transmission. Given the disproportionate impact of the opioid epidemic on Black Americans and the risks associated with opioid misuse, the current study aims to investigate sociostructural factors, history of violence, and sexual risk factors associated with transactional sex among Black men and women. A sample of n = 375 Black adult Kentuckians reporting opioid misuse completed a survey including transactional sex, sociostructural, violence history, and sexual risk measures. Results of chi-squares and independent samples t-tests revealed that compared to men who did not report engaging in transactional sex, men who engaged in transactional sex were less educated, reported being sexually assaulted or having an unwanted sexual experience in their lifetime, and were more likely to use opioids or cocaine before or during sex in the last year. Women who engaged in transactional sex had a history of violence, more structural barriers, higher psychological distress, and engaged in more sexual risk behaviors compared to women who did not engage in transactional sex. Implications for future research and interventions with this population are discussed.
With the rise in opioid use among Black Kentuckians (Slavova et al., 2021), there is growing public health concern about the impact on HIV risk (Centers for Disease Control and Prevention, 2021). Although Black Americans make up 9% of Kentucky’s population, they make up 32% of the overall cases of HIV (Kentucky Department for Public Health, 2022). In 2020, the rate of HIV among Black Kentuckians was 3.45 times higher than that of White Kentuckians (Kentucky Department for Public Health, 2022). In addition, in Kentucky, 23% of people diagnosed with HIV in the last decade have received a concurrent diagnosis of AIDS (Kentucky Cabinet for Health and Family Services, 2020). Among those who are concurrently diagnosed, nearly a quarter have an undetermined transmission route (Kentucky Cabinet for Health and Family Services, 2020). Although research has shown that opioid use increases HIV risk, little is known about other sources of transmission, such as transactional sex.
Transactional sex is the exchange of sex for drugs, money, shelter, and other goods (Ellis et al., 2023; Menza et al., 2020) and is relatively common among people with opioid use disorder (Ellis et al., 2023). A recent study on men and women seeking treatment for opioid use disorder found that Black Americans were the second highest racial group to engage in transactional sex (29.6%) compared to 23.1% of White and 30.4% of Latino groups (Ellis et al., 2023). Black Americans may face structural barriers that place them at risk of engaging in transactional sex.
The Theory of Gender and Power suggests that sociostructural factors produce inequalities between men and women that directly influence sexual health outcomes among women (Connell, 1987). Structural factors are “economic, social, policy, and organizational environments that ‘structure’ the context in which risk production occurs” (Marshall et al., 2009, p. 7) and are important determinants in the acquisition, transmission, and prevalence of HIV among Black Americans. Wingood and DiClemente (2000) expanded this theory, to communicate how gender-based inequalities manifest into exposure and risk factors that may increase women’s risk of HIV infections. In recent years, research has examined structural factors that increase HIV risk among high-risk populations, including injection drug use and transactional sex. In a study of incarcerated White women in Kentucky who use drugs, participants who engaged in transactional sex were more likely to report financial problems prior to incarceration (Dickson et al., 2023). However, little is known about what places Black women or men who misuse opioids at higher risk of engaging in transactional sex.
While current literature highlights multiple factors that increase the likelihood of transactional sex among high-risk White adults, there is a dearth of information about Black Americans. In the United States, most research related to transactional sex has been limited to White Americans (Allen et al., 2020), transgender women of color (Arrington-Sanders et al., 2022), and Black men who have sex with men (MSM) (Biello et al., 2021; Dangerfield et al., 2020; Rucinski et al., 2020). The correlates of transactional sex among Black Americans, however, have received limited scholarly attention. Furthermore, the lack of literature on transactional sex in Black heterosexual men is a notable gap in current research (Rosen et al., 2022).
The purpose of the current study is to investigate the difference in sociostructural factors, history of violence, and sexual risk behaviors between Black men and women who engage in transactional sex and those who do not in a sample of adults who misuse opioids. This study is guided by two research questions:
1. Are there significant gender differences between those who engage in transactional sex to receive goods versus to give goods?
We hypothesize that women will be more likely to engage in transactional sex to obtain material needs, and men will be more likely to engage in transactional sex to provide material needs.
2. Are there significant differences in demographics, sociostructural factors, history of violence, and sexual risk behaviors between Black men and women who engage in transactional sex and those who do not?
We hypothesize that there will not be significant differences in demographics between men and women who engage in transactional sex and those who do not. However, women who engage in transactional sex will have more significant sociocultural factors, a history of violence, and sexual risk factors compared to women who do not engage in transactional sex.
Method
Participants and Procedures
The data for this study are from Aim 2 of the Research Examining Factors Associated with The Opioid Crisis among Underserved African Americans (REFOCUS) Study. REFOCUS is a mixed-methods study on nonmedical prescription opioid misuse among Black adult men and women between the ages of 18 and 69. Aim 2 is quantitative data collection by way of interviews to understand structural, social, and cultural patterns of nonmedical prescription opioid use and misuse, illicit drug use, and drug treatment. Aim 2 data collection began in 2021 and is currently still in progress. Eligible participants had to (1) self-identify as Black or African American, (2) be at least 18 years old, (3) speak English, and (4) have used an illicit or prescribed opioid beyond the way it was prescribed at least once in the past 6 months. For the purposes of this study, participants were told “Illicit opioids include heroin and fentanyl; prescription opioids are a type of medication prescribed to treat pain. Common examples of prescription opioids are oxycontin/oxycodone, Lortab/hydrocodone, Percocet, methadone, suboxone, and codeine cough syrup.”
Following approval from the University of Kentucky’s Institutional Review Board, researchers completed targeted recruitment using social media (e.g., Facebook, Instagram, Twitter) and flyers in zip codes with the largest Black populations within the study’s geographical catchment area. Race-matched recruiters canvassed neighborhoods to talk to residents about the research study. In addition, researchers obtained permission from local businesses, public service providers, and organizers of community events to recruit and hand out flyers to community members directly. Participants completed a screener survey either in-person at recruitment events or over the phone by calling the study’s phone number. During the screener survey, people were asked to include their age, race, and gender and were asked about their illicit and prescription opioid misuse in the past 6 months.
Study locations were publicly known places in two urban cities and within a three-mile radius of zip codes with between 40% and 95% Black residents. One location was a university building, and the second location was a community center housing Black-owned businesses. Each study location was equipped with snacks, a community resources list, opioid overdose education materials, and free Narcan nasal spray, an emergency treatment for suspected opioid overdose. All participants provided informed consent before the interview. Laptops were programmed to collect data using the Computer Assisted Personal Interviewing (CAPI) software and Audio Computer Assisted Self-Interviewing software (ACASI). The interview process took between 1.5 and 2.0 hours including the consent process, interview, optional urine drug screen, and overdose education. Participants were paid $40 cash for completing the interview.
Sample
The final sample for the current study was n = 375 Black adults. The majority of the sample was male (n = 232; 61.7%). Participants were aged 18 to 69 (M = 45.5), the majority were heterosexual n = 314 (87.3%) and over half (51.5%) reported being homeless within the last year. Finally, several of the participants in the sample had been involved with the criminal justice system in their lifetime (91.9%), however, most of them were not arrested within the last year (73.4%).
Measures
Demographics
Participants reported their age, education (in years), and sexual preference. Options for sexual preference were men and women, women only, and men only. For the purposes of this study, a dichotomous heterosexual variable was created (1 = yes; 0 = no).
Sociostructural Factors
Employment Status
Participants were asked about their usual employment patterns. Response options were full-time (40 hours per week), part-time (regular hours), part-time (irregular, daywork), student, retired/disabled, unemployed, and illegal activities in a controlled environment. A dichotomous variable was created for those who had full-time work (1) and those who did not (0).
Homelessness
Participants were also asked to report if they were homeless in the past year (1 = yes; 0 = no).
Arrest History
Participants were also asked the number of times they were arrested in their lifetime. Response options were never, one to three times, four to five times, six to nine times, and over 10 times. Due to over 91.8% of the sample being arrested in their lifetime, a dichotomous variable was created for those that were arrested over 10 times or more (1 = yes; 0 = no).
Psychiatric Symptoms
Participants reported whether they experienced psychiatric symptoms in their lifetime using the modified Addiction Severity Index (ASI-V), Fifth Edition (McLellan et al., 1992). A total of eight items assessed the participants’ 30-day experiences of mental health with responses of 1 = yes and 0 = no. All items were summed to create a composite measure with scores ranging from 0 to 8 (α=.78). Items measured lifetime reports of serious depression, anxiety, tension, hallucinations, inability to control violent behavior, thoughts of suicide, suicide attempts, trouble concentrating and remembering, and if they were prescribed medications. Sample items included “Have you had a significant period that was not a direct result of drug/alcohol use, in which you have experienced serious anxiety or tension in your lifetime?,” “. . . experienced trouble controlling violent behavior in your lifetime?,” and “. . . prescribed medication for any psychological or emotional problem in your lifetime?”
History of Violence
Participants were asked if they had ever been sexually assaulted, physically assaulted, assaulted with a weapon, or had an unwanted sexual experience. Response options to these four questions were yes = 1 and no = 0.
Sexual Risk Behaviors
Participants were asked if they had used alcohol, opioids, powder cocaine, and cannabis before or during sex in the last year. Response options to these four questions were yes = 1 and no = 0. Participants were also asked if they had sex without a condom in the last 12 months. In addition, they were asked to report which STIs they had in their lifetime. A dichotomous variable was created such that those who reported having an STI in their lifetime were coded as yes.
Transactional Sex
Participants were asked six questions about transactional sex. The first three questions measured engaging in transactional sex to receive goods or money: (1) “I had sex with someone who was not a regular sex partner because I needed help with paying for expenses such as housing, groceries, utilities, and other bills,” (2) because “I needed help with expenses related to children or someone else who depends on me for financial support,” and (3) because “I needed help paying for things I couldn’t afford myself.” The last three questions measured engaging in transactional sex to give goods or money: (4) “Someone who was not a regular partner has had sex with me so I could help them with expenses such as housing, groceries, utilities, and other bills,” (5) “someone who was not a regular partner has had sex with me so I could help them with expenses related to children and or someone else who depends on them for financial support,” and (6) “someone who was not a regular partner has had sex with me so I could help them with paying for things they couldn’t afford. A dichotomous variable was created to measure lifetime transactional sex.” If a participant responded yes to any of the sex questions, they were coded as engaging in transactional sex. The number of types of transactional sex people engaged in ranged from 1 to 6.
Analysis
Data were analyzed using IBM SPSS Statistics version 28. Chi-square analyses were conducted to analyze the differences between men and women who engaged in transactional sex and those who did not. To analyze differences in continuous variables, independent sample t-tests were conducted.
Results
Transactional Sex
Overall, 36.4% of the entire sample reported engaging in transactional sex. For participants who engaged in transactional sex, 23.0% (n = 84) had sex to afford to pay for things they could not afford and 74% (n = 79) had sex to pay for expenses such as housing, groceries, and utilities. Only 12.5% (n = 46) of participants had unprotected sex with someone who paid them for sex in the last 6 months. Over one-fourth of participants reported that they misused prescription drugs to have better sex (n = 81; 22.1%). Only one woman reported having sex to obtain prescription drugs and one woman reported having sex to obtain illegal drugs.
There were no significant gender differences in lifetime engagement in transactional sex (p = .17). However, there were significant gender differences in the types of transactional sex that men and women engaged in (see Table 1). Women were more likely than men to engage in transactional sex because they needed housing, groceries, utilities, and other bills (p < .001), to support their children or other dependents (p < .001), and money for things they could not afford (p = .004). In contrast, men were more likely to engage in transactional sex to provide money for housing, groceries, utilities, and other bills (p = .01), to help their sex partner support their children or other dependents (p = .02), and to provide money to help their sex partner pay for things they cannot afford (p = .01).
Gender Differences in Types of Transactional Sex (n = 364).
Note. p-values are results of chi-square analysis.
Gender Differences
Results of the chi-square and independent sample t-test analysis showed that there were significant differences between men and women who engaged in transactional sex and those who did not (see Table 2). The results are presented by gender. There were significant differences in educational level between men who engaged in transactional sex (p = .04). Men who engaged in transactional sex had fewer years of education than those who did not engage in transactional sex. There were no significant differences in sociostructural factors such as employment, number of arrests, homelessness, or 30-day psychiatric symptoms between men who engaged in transactional sex and those who did not. Regarding experiences of violence, more men who engaged in transactional sex reported being sexually assaulted (p = .03) and having an unwanted sexual experience in their lifetime (p < .001). Finally, when exploring differences in sexual risk factors, men who used opioids (p = .01), or cocaine (p = .02) before or during sex within the last year were more likely to report engaging in transactional sex. For men, being physically assaulted, being assaulted with a weapon, alcohol and cannabis use before or during sexual intercourse, condomless sex in the last 12 months, and STI history were not significantly different between those who engaged in transactional sex and men who did not.
Demographic, Sociostructural Factors, and Sexual Behavior Differences by Gender and Transactional Sex (n = 364).
There were significant differences between women who engaged in transactional sex and those who did not. Women who engaged in transactional sex were more likely to report sociostructural issues such as being arrested 10 or more times (p = .002), being homeless in the past year (p < .001), and having higher psychiatric symptoms in the last 30 days (p = .01) compared to women who did not engage in transactional sex. Women who engaged in transactional sex were also more likely to report experiencing sexual assault (p = .003), physical assault (p < .001), an unwanted sexual experience (p = .01), or being assaulted with a weapon (p = .01) than those who did not engage in transactional sex. Women who engaged in transactional sex reported alcohol use (p = .01) and opioid use (p = .04) before or during sex within the last year. Cannabis use and cocaine use before or during sex in the last year were not significant. Finally, women who engaged in transactional sex reported having sex without a condom in the last 12 months (p < .001) and a lifetime history of STIs (p < .001) compared to women who did not engage in transactional sex.
For both men and women age, education, and full-time employment status were not significantly different.
Discussion
This study aimed to better understand the demographic, sociostructural, violence, and sexual risk factors associated with transactional sex among Black men and women who report opioid misuse. Results demonstrated that Black women are more likely to engage in transactional sex to support their dependents or for money compared to Black men. In addition, Black women who engaged in transactional sex were more likely to experience sociostructural barriers, have a history of violence, and engage in sexual risk behaviors.
Heterosexual Black Men and Transactional Sex
Heterosexual Black men in the current study reported engaging in transactional sex. This finding adds to the literature as most research on transactional sex focuses on Black MSM. Although Black men who misuse opioids may find themselves vulnerable to impoverishment (Nicholson & Ford, 2018), the men in the current study were engaging in transactional sex because their sex partner needed money, resources, or goods from them. Similar to previous research, the men in the current study may also engage in transactional sex to exert power and control over their female counterparts (Magni et al., 2020) or to express their masculinity by demonstrating their ability to provide despite social disempowerment. Previous research on Mexican men found that those who engage in transactional sex often framed their experiences as reciprocal gift-and-aid giving rather than a sex exchange (Wentzell, 2014). Creating these definitions was critical to their ability to perform masculinity through transactional sex (Wentzell, 2014). The same may be true for Black men. Furthermore, for Black men, expressions of masculinity through transactional sex may also be linked with their experiences of sexual assault and unwanted sexual experiences.
The men in our study who engaged in transactional sex were more likely to report that they were victims of sexual assault and unwanted sexual experiences. Research on heterosexual Black men’s experiences of sexual abuse is limited due to the shame associated with it and its disclosure (Curry, 2019; Livingston, 2021; Myrie & Schwab, 2023; Zounlome et al., 2021), which negatively impacts data collection on this topic. However, recent research on Black men who were incarcerated in Kentucky showed that sexual abuse leads to an increase in emotional restrictiveness (Thorpe et al., 2022). With this finding, it could be inferred that Black men may engage in transactional sex to have sexual intercourse without emotional intimacy. In addition, research on Black MSM has shown that childhood sexual assault is linked to illicit drug use; drugs were used to cope with feelings of shame, unprocessed feelings related to the trauma, and lack of familial support and protection regarding their assault (Dangerfield et al., 2020). More qualitative research is needed to understand the relationship between sexual assault and engagement in transactional sex for Black men who misuse opioids.
Sociostructural Risk Factors and Violence Against Women and Sexual Risk
Similar to previous research, women who engaged in transactional sex were more likely to experience sociostructural risk factors such as violence (Dickson et al., 2023; Dunkle & Decker, 2013), homelessness (Jenness et al., 2011; Kaljee & Chen, 2011), and criminal justice involvement (Sherman et al., 2018). These results are consistent with previous literature that details how cyclical police contact and homelessness create barriers to employment and other income-generating ventures (Menza et al., 2020; Rosen et al., 2022). Women may also engage in transactional sex to improve their social status and secure housing, especially if they have dependents (Stoebenau et al., 2016). For Black women who misuse opioids, gendered racism also impacts the socioeconomic adversities that they experience (poverty, incarceration, hiring discrimination, etc.), as these conditions are intensified under systemic oppression (Essed, 1991; Spates et al., 2020). For these women, engaging in transactional sex may be a viable method to navigate socioeconomic factors that impact their ability to routinely acquire basic needs.
Women may engage in transactional sex more than men due to gender inequality (Kilburn et al., 2018). There is a stereotype that women may be powerless within heterosexual relationships (Stoebenau et al., 2016). Recalling the Theory of Gender and Power (Connell, 1987), transactional sex creates an inherent power imbalance between the two partners. During heterosexual relations, the power in the sexual relationship is typically bestowed upon the male partner due to gender norms and expectations (Wingood & DiClemente, 2000). Male control over sexual decision-making may reduce women’s ability to influence the conditions of sex (Dunkle & Decker, 2013). Male control may be exerted through violence (e.g., sexual assault, physical assault) and coercion (e.g., pressure to not use condoms), which can become pathways to HIV infection through unsafe sex practices (Dunkle & Decker, 2013). Several studies have suggested that sexual power indirectly influences HIV risk through inconsistent condom use (Logan et al., 2003; Pettifor et al., 2004; Pulerwitz et al., 2002). This finding could explain why women who engaged in transactional sex were significantly more likely to report not using a condom in the last 12 months and higher rates of STIs.
For the women in our sample, the risk exposures of living in poverty and experiencing homelessness are particularly salient (Wingood & DiClemente, 2000). Gendered disempowerment coupled with financial need may compromise the women’s ability to negotiate for increased condom use and avoid unsafe sex practices. Similar to research on incarcerated White women (Dickson et al., 2023), women in the current study also had more economic motivations for engaging in transactional sex; therefore, it is possible that economic dependence on sexual partners contributes to the increased risk of HIV among Black women who report opioid misuse.
Limitations
There are several limitations. First, our study sample was majority heterosexual; we were unable to look at differences based on sexual orientation. Second, there were some structural factors we did not measure (e.g., food insecurity) and family factors (e.g., adverse childhood experiences [ACEs]) that may influence people’s decisions to engage in transactional sex. Third, we only asked participants about transactional sex with people who were not their regular sex partners; however, people engage in transactional sex within their relationships. Research has shown that Black women engage in transactional sex with their partners for financial security and resources and often form romantic relationships for economic reasons (Dunkle et al., 2010). As a result, the rates of transactional sex may be underreported in our current study. Fourth, temporal associations of violence were not recorded in relation to transactional sex. While those who engaged in transactional sex were more likely to have experienced violence, data was not collected to determine if violence preceded, ensued during, or followed engagement in transactional sex. Similarly, we do not know if the reported arrests were related to sex work. In addition, very few participants engaged in transactional sex for illegal drugs, but rather for survival. Finally, these findings may have limited generalizability.
Implications
According to Wamoyi and colleagues (2019), an accurate assessment of transactional sex should involve a clear distinction between transactional sex and sex work. We also propose considering how structural factors informed by race (e.g., racism, drug policies) influence engagement in transactional sex for Black Americans who misuse opioids compared to their non-Black counterparts. Accurately capturing how these factors inform sexual decision-making for Black men and women provides a starting point for intervention.
Research investigating the access and utilization of social services and health care among Black men and women who misuse opioids is needed. This research can inform culturally responsive interventions and policies to mitigate sociostructural, violence, and sexual risk factors as a form of practical preventive care. Interventions should incorporate education and resources for basic needs, employment, incarceration, and substance use treatment. Findings by gender can inform the development of programs to address violence risk factors within gendered racial contexts specific to Black Americans.
Based on the prevalence of lifetime STIs and rates of condomless sex within our population, coupled with the high rates of HIV among Black Kentuckians, Black men and women who misuse opioids may benefit from HIV prevention tools such as pre-exposure prophylaxis (PrEP). Efforts to increase PrEP uptake among men and women who misuse opioids have not been as effective (Beck et al., 2022). Previous research has shown people who misuse opioids have limited awareness of PrEP, ranging from 7% to 23% (Beck et al., 2022). Thus, this population may benefit from PrEP education and access to PrEP in OUD treatment programs (Beck et al., 2022; Jones et al., 2019). Increasing knowledge of PrEP and access to HIV testing can increase willingness to initiate PrEP (Ni et al., 2021). Although PrEP has very few side effects (Centers for Disease Control and Prevention, 2022), the perceived side effects are still a major barrier to PrEP use among people who use drugs (Mustanski et al., 2013; Shrestha & Copenhaver, 2016) and Black women (Willie et al., 2022). In addition, stigma and concerns about being perceived as HIV-positive serve as a barrier to PrEP uptake among these two populations (Bond & Gunn, 2016; Crooks et al., 2023; Shrestha & Copenhaver, 2016). Moreover, some studies reported that people who use drugs perceive physicians to be treatment gatekeepers, stating that physicians are reluctant to prescribe PrEP because they do not believe that people who misuse opioids would adhere to the use guidelines (Ni et al., 2021). Medical providers need to discuss all forms of PrEP with Black Americans who misuse opioids so they can decide which method works best for their lifestyle (e.g., daily pills or injectable PrEP). Providers should also address the multilevel challenges to PrEP uptake for Black Americans who misuse opioids (Biello et al., 2021).
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the National Institute on Drug Abuse (NIDA; R01-DA049333; PI: Danelle Stevens-Watkins). The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
