Reconceptualizing Safer Sex: Women's Protective Health Strategies During Transactional Sexual Exchanges

Background: Transactional sex has been associated with increased risk of adverse health outcomes, including STI, physical and sexual violence. Understanding the factors that impact women's ability to protect themselves during transactional sexual encounters is necessary in order to design effective sexual healthcare programs. STI reduction can only occur by addressing the larger contexts of violence, drug use, and dependence on men for economic survival. Objectives: To examine health protective strategies among women engaging in transactional sex in Indianapolis, Indiana. Methods: Women who recently engaged in transactional sex were recruited utilizing incentivized snowball sampling, completed an interview that included open-ended questions about protective health behaviors, and were offered STI testing. Interviews were recorded and analyzed for thematic content. Results: 25 participants aged 19-65 were interviewed. Most reported intermittent condom use however a variety of other protective strategies were utilized. These included: visually assessing johns, avoiding men who are perceived as dangerous, preselecting sex locations, carrying condoms, and avoiding ejaculate. 15/25 (60%) tested positive for at least one STI. Conclusions: Interventions to increase sex worker safety may be improved by recognizing that women engaging in transactional sex routinely utilize risk-reduction techniques in addition to condom use. It is critical to understand how self-protective behaviors are assigned monetary values during the negotiation of these interactions. Despite being motivated to use condoms, this group's ability to consistently negotiate condoms was low. Increased understanding of other protective strategies will improve STI control efforts for this population by encouraging alternative methods for promoting health.