Alcohol and transactional sex: How risky is the mix?
Introduction
Between 1996 and 2006, 18 million Africans died from AIDS (UNAIDS, 2008); many millions more are infected with other sexually transmitted infections (STIs). In the context of a sugar plantation in Tanzania, using a mixed-method approach, we examine both popular discourse about how alcohol use and transactional sex (TS) increase risk of exposure to STIs, and quantitative associations between alcohol use, participation in TS, and prevalent STIs.
Social meanings of alcohol in Africa are often contradictory. Alcohol holds a central role in ritual (marriage, funerals, coming-of-age ceremonies) (Ambler, 1991, Colson and Scudder, 2001, Crush and Ambler,, Karp, 1980), yet ritualistic use is greatly surpassed by everyday consumption for leisure (Bryceson, 2002). Alcohol holds, simultaneously, “good” social values (relaxing, being happy, spending time with friends, increasing strength) and “bad” social values (loss of respect and money, causing drunkenness or bad behavior) (Bryceson, 2002).
Alcohol use can lead to disinhibition and potentially risky sex (Fisher et al., 2007, Kalichman et al., 2007, Mbulaiteye et al., 2000, Miller, 2003, Shaffer et al., 2004). Bars link alcohol and risky sex, becoming “sexual networking contexts” (Fritz et al., 2002, Kalichman et al., 2007, Lewis et al., 2005, Morojele et al., 2006) where individuals attempt to quench “thirst” for sex (Pietila, 2002). Many women across sub-Saharan Africa report that sex partners buy them drinks for sex (Dunkle et al., 2004, Maganja et al., 2007), and women who sell sex in drinking establishments are at more risk than those who sell from home (Yadav et al., 2005). In addition, more men than women believe that alcohol will enhance sexual activity and desires, and so drink before sex (Kalichman, Simbayi, Cain, & Jooste, 2007). Thus for African women, risk for unsafe sex may be influenced more by their partners' drinking than their own (Morojele et al., 2006, Morojele et al., 2004).
The meaning of exchanging money or gifts for sex varies widely in sub-Saharan Africa. Whereas by western norms, payment marks sex as prostitution and precludes romantic love, most women in Africa who are paid for sex are not sex workers. Payment can signify a committed relationship, an indication of respect, a gift meant to engender affection, an obligation met, or an opportunity for the giver to demonstrate his prestige to other men (Dunkle et al., 2007, Leclerc-Madlala, 2004, Moore et al., 2007, Stoebenau et al., 2009). Sex becomes a commodity to exchange for educational opportunities, employment, connections to social networks, and luxury consumable items (Chatterji et al., 2005, Leclerc-Madlala, 2004, Pietila, 2002). Variation in cultural norms across Africa result in a range of tolerance toward TS; motivation for TS is as diverse as what is desired.
Béné and Merten (2008) describe two dominant tropes of TS. In one, women are victims; economic constraints, social pressure, and male-dominated social norms direct their risky sexual behavior. In the other trope, women are social agents, using sexual relationships to get money and gifts. Reality for most women lies between these poles, with some negotiating in a context of unequal gender power relations (Béné & Merten, 2008).
TS has been associated with STI/HIV risk throughout sub-Saharan Africa (Cote et al., 2004, Dunkle et al., 2004, Luke, 2002). It is not the transactional aspect per se that makes this sex risky. TS is risky because women may agree to sexual encounters they would not have sought otherwise, and often do so on men's terms (Béné and Merten, 2008, Dunkle et al., 2004). Considering that TS represents both a powerful social phenomenon and a proven risk for STI, surprisingly little is written about how men and women in Africa view this risk (Dunkle et al., 2004).
We carried out an ethnographic and epidemiologic study during 2002–4 with the residents of the Tanzania Sugar Enterprises (TSE), a sugar plantation located 32 kilometers from Moshi, a city in northern Tanzania. (TSE is a pseudonym, as are names of camps and villages.) Moshi's population is 150,000, and Chagga people, traditionally agriculturalists, predominate. TSE, however, draws laborers from across Tanzania. Established in 1932, the 55-square mile TSE was family-owned until nationalized in 1980. In 2000, nearly bankrupt, the plantation was sold to Mauritian investors. Within two years the new management reduced employee rolls 50% and began turning a profit. In 2004, the plantation employed 3800 people and housed over 9000 adults.
Plantation residents described how drinking alcohol and engaging in TS—independently and in combination—led to increased STI exposure. By examining popular discourse, we uncovered residents' normative portrayal of life at TSE, and learned how people talked (but not necessarily behaved) about sex and HIV. To understand individual behavior and risk for STI, we analyzed residents' self-reported sexual behaviors, alcohol use, and TS practices. In sum, this paper has three objectives: 1) to explore popular discourse about how alcohol use and TS increase risk of exposure to HIV and STI, perhaps differently for men and women; 2) to measure associations between self-reported behaviors (alcohol use and TS) and infection with herpes simplex virus type-2 (HSV-2), syphilis, or HIV for men and women; and 3) to identify points of similarity and discord between qualitative and quantitative findings, and interrogate the relationship between popular discourse and self-reported behavior.
Section snippets
Methodology
In 2002–2003 (pilot study) and 2004 (cross-sectional prevalence study), we collected three types of data at TSE plantation in northern Tanzania: 1) qualitative (focus group discussions (FGDs) and in-depth interviews (IDIs)), 2) quantitative (survey with structured questionnaires), and 3) clinical (HSV-2, syphilis, and HIV test results). These studies were conducted as a doctoral dissertation research project (Norris, 2006) with funding from Yale University and a Fulbright Hayes Doctoral
Plantation life
Almost all 3800 workers at TSE lived in one of ten residential, company-maintained “camps.” Permanent workers had one or two rooms in small cement block structures, and were permitted to have families with them. The predominantly male seasonal workers constituted approximately 25% of the work force during peak cane cutting season and lived four to a room in dormitory-style buildings. They could not have dependents live with them. Both unemployed and employed individuals resided at TSE.
For those
Discussion
In large part, findings from our mixed-methods study were in agreement. TSE residents described a culture of drinking, where people without alternative social outlets came together in bars and used disposable income for alcohol. Because alcohol increases tamaa (desire or longing) for sex, and removes shame, participants explained, sexual encounters started at the bar were risky. Correspondingly, our epidemiologic data showed that drinking and abusing alcohol were significantly associated with
Conclusion
Given that alcohol abuse and TS pose significant risks for STIs, we suggest several areas of intervention. TS occurs when some individuals lack opportunities or resources they want or need. Reduction of TS will require continued long-term investment in social change. In the short-term, however, places like TSE represent great opportunities for profit-generating cooperative schemes so women will have something other than alcohol or sex to sell. More acutely, risky sex is initiated where people
Acknowledgements
We acknowledge the support of Yale's Center for Interdisciplinary Research on AIDS for funding the initiation of the study, as well as support from the Fulbright Fellowship for Doctoral Research Abroad and the Yale Center for International and Area Studies to complete the study. This paper represents a portion of Norris's doctoral dissertation, and she was supported at Yale by the NIH Medical Scientist Training Program and an NIMH training grant as a pre-doctoral fellow with the Center for
References (40)
- et al.
Women and fish-for-sex: transactional sex, HIV/AIDS and gender in African fisheries
World Development
(2008) - et al.
Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa
The Lancet
(2004) - et al.
Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: prevalence, predictors, and associations with gender-based violence
Social Science & Medicine
(2007) - et al.
Alcohol expectancies and risky drinking among men and women at high-risk for HIV infection in Cape Town South Africa
Addiction Behavior
(2007) The ‘dop’ system, alcohol abuse and social control amongst farm workers in South Africa: a public health challenge
Social Science & Medicine
(1999)Alcohol consumption among South African farm workers: a challenge for post-apartheid health sector reform
Drug and Alcohol Dependence
(2000)- et al.
Alcohol use and sexual behavior among risky drinkers and bar and shebeen patrons in Gauteng province, South Africa
Social Science & Medicine
(2006) “Drunks, brewers, and chiefs”
Anthropology and the analysis of ideology
Man
(1979)
The factors influencing transactional sex among young men and women in 12 sub-Saharan African countries
Social Biology
For prayer and profit: The ritual, economic, and social importance of beer in Gwembe District, Zambia, 1950–1982
Transactional sex is the driving force in the dynamics of HIV in Accra, Ghana
AIDS
Baseline questionnaire: Economic intervention assessment
Detecting alcoholism: the CAGE questionnaire
JAMA
The association between HIV infection and alcohol use: a systematic review and meta-analysis of African studies
Sexually Transmitted Diseases
Herpes simplex virus 2 infection increases HIV acquisition in men and women: systematic review and meta-analysis of longitudinal studies
AIDS
The association between alcohol use, sexual risk behavior and HIV infection among men attending beerhalls in Harare, Zimbabwe
AIDS and Behavior
Alcohol use and sexual risks for HIV/AIDS in sub-Saharan Africa: systematic review of empirical findings
Preventative Science
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