In a sample of low-SES women from the Portland, Oregon metropolitan area, 13.6% reported receiving money or drugs for sex in the prior 12 months. This estimate of transactional sex is similar to those in studies conducted on the West Coast of the U.S.6–8 but lower than estimates in U.S. East Coast samples 9–11 and a national U.S. sample.5 Similar to prior studies, Black women, older women, and women who reported sexual violence were more likely to report transactional sex.6,8,9,11,15
Childhood trauma was pervasive among the women in our sample. Over 90% of women experienced ≥ 1 ACE, an estimate significantly higher than recent prevalence estimates among U.S. adults.27 Furthermore, ACEs were associated with an increased probability of transactional sex independent of the effects of demographics, incarceration, homelessness, substance use, sexual behavior, and recent sexual intimate partner violence. Experiences of childhood sexual abuse were not the only ACEs associated with transactional sex; women who reported transactional sex were more likely to experience emotional abuse and to report living with a family member with mental illness. Finally, we observed a dose-response relationship between ACEs and the likelihood of transactional sex.
Our findings are consistent with the 2012 Behavioral Risk Factor Surveillance Survey (BRFSS), wherein women who experienced more ACEs were more likely to report a composite outcome of HIV risk behavior that included exchange sex 16 and a study of South African women which found an association between a different childhood trauma score and transactional sex.28,29 Similar dose-response relationships have been found with myriad other behaviors and physical and mental health outcomes.30 The development of life course-based, public health interventions to address the effects of trauma and harness the resilience that can come from surviving trauma are essential.31
Women who reported both opioid and methamphetamine use were more likely to report transactional sex than women who used neither or either substance. In Oregon and other U.S. jurisdictions, there has been increasing overlap of methamphetamine and opioid use since at least 2011.32–34 Use of opioids and methamphetamine may produce a desirable, synergistic high; women who have experienced trauma may only be able to have sex while on methamphetamine; methamphetamine may mitigate opioid withdrawal symptoms; methamphetamine may be less stigmatized and easier to obtain; methamphetamine may allow people to function to complete daily task; and/or, methamphetamine may be used as a form of currency.35 The implications of this overlap for sexual health require further investigation.
Despite clear indications for frequent HIV testing and PrEP, access to, and uptake of, biomedical prevention among women who reported transactional sex was limited. Self-reported condomless sex with a casual partner, HCV infection, and bacterial STI were nine, five, and two times more likely among women who reported transactional sex, respectively. However, among women who reported transactional sex, only 23% tested for HIV in the past year, 6% had ever heard of PrEP, and none had taken PrEP. Research indicates that women vulnerable to HIV infection view PrEP as an important HIV prevention option, but may not be hearing about PrEP from their providers.36 These data behoove medical and public health communities to develop programs to increase knowledge of, and access to, screening and biomedical HIV prevention as part of comprehensive sexual health services for HIV-vulnerable women.
Our study has several limitations. First, NHBS is cross-sectional; we cannot infer a causal relationship between the examined vulnerabilities, behaviors, and health outcomes and transactional sex. Second, the assessment of ACEs and other variables was retrospective and subject to recall bias.37 Third, the definition of transactional sex is too narrow and does not capture the range of practices that comprise transactional sex. Thus, the study may underestimate the prevalence of transactional sex and the context of the transactional sex practices captured in this study may not generalize to the context of other transactional sex practices. Fourth, the sample of women reporting transactional sex was relatively small, limiting our statistical models to a select set of variables to avoid overfitting. Finally, we recruited a racially diverse population rarely represented in Portland, Oregon, but our sample may not be representative of the area.