Women feared violence if they suggested condom use. Also, in situations of sexual violence, condomless sex was generally imposed by the aggressor so women had neither control over the assault nor their sexual health. Structural violence should also be acknowledged, as GBV is embedded in social systems and institutions [ 92 , 93 ]. However, most strategies to prevent gender-based violence have focused on individual behaviours and health outcomes, rather than the elimination of GBV as a violation of human rights rooted on unequal power dynamics.
As previous research has suggested, there is the need to equate the power relations between women and men and promote community-level changes, shifts in public discourse, and to focus on shaping social norms across all social ecology levels i. Contrary to what previous research has suggested [ 98 ], no clear relationship was found between condom use and transactional sex with either clients or non-clients in the quantitative studies.
Qualitative data suggested that some women might agree on having condomless sex in exchange for larger amounts of money, and to avoid losing clients to other transactional sex workers.
Violent and coercive interactions with clients were found to hinder negotiating condom use as women were often coerced or forced to have condomless sex. Transactional sex exchanges were riskier when women were experiencing withdrawal symptoms, as the urge to get money to use drugs prevented them from being selective with clients, and women were more vulnerable to being sexually exploited by clients. Transactional sex in poor conditions and in outdoor venues e. Transactional sex in indoor venues e. Transactional sex was also positively associated with having multiple sexual partners—which was linked to a decrease in condom use—, initiating sex at a younger age, and being less likely to have steady sexual partners.
The data around transactional sex and sexual health risks suggest that transactional sex should not be treated as a sexual risk practice but rather a situation in which women are more exposed to sexual risks. As for any other women, experiencing physical and sexual violence exposes transactional sex workers to sexual health risks. Structural violence should be considered and addressed in relation to transactional sex. HIV positive individuals are more likely to use condoms once they are aware of their HIV status [ , ]. Condomless sex among HIV positive individuals seems to be associated with the increased effectiveness of new treatments for HIV [ ].
Sexual transmission of HIV among serodiscordant couples has also been found to be low [ ], suggesting high rates of condom use and effectiveness of antiretroviral therapy. Data from this review suggested a tendency for HIV positive women to be more exposed to sexual risks, including sexual violence, compared to HIV negative women.
Low risk awareness i. In contrast, having had a free HIV antibody test was found to be linked to inconsistent condom use among women engaged in transactional sex. An explanation for this could be that testing might decrease risk awareness, and lead women to have condomless sex. Besides, it is important to acknowledge that WHOD experience stigma and discrimination due to the intersectionality of different characteristics of their identity i. Women from the Lesbian, Gay, and Bisexual LGB community experience social and health inequities [ , , , , , , , ].
These comprise poorer mental health [ , , , , ], substance use [ , , ] and physical health including STIs [ ]. Consistent with recent research [ , ], the findings from this review suggest that LGB women experience higher sexual risks, in comparison with their heterosexual counterparts.
These barriers are consistent with previous research on the barriers to condom use [ , , , ]. Other barriers and facilitators were linked to preferences, negotiation, skills and availability of condoms. Condom use was facilitated when women discussed their use with their partners, and when there was an agreement on using condoms.
Women were more likely to report condom use if they were feeling in control over the decision of having sex with condoms. Having a drug-using partner was associated with condomless sex. Condoms were less likely to be used when sex was not planned as condoms were potentially not available in that situation.
Moreover, condomless sex was common in situations in which condoms were not available or women could not afford to buy them. These findings are consistent with previous research [ , , , ], and they relate to the positive impact of self-efficacy and communication on condom use, as well as the importance of empowering women to negotiate and gain control over sexual health decision-making processes.
Also, partner characteristics, preferences and decision-making should be considered as factors associated with condom use. Other individual-level e. The impact of culture in health and health behaviours has been especially neglected within health services research and health interventions [ , , , ]. Furthermore, it is important to consider that all the included papers in this review exclusively researched on male condoms. Among women who did not engage in transactional sex, the relationship between condom use and substance use was unclear.
The number of sexual partners and scope of sexual acts were however higher when women used drugs. Substance use, and particularly injecting drug use, was related to engaging in transactional sex.
Transactional sex was more common when women experienced withdrawal symptoms, a situation when women were also less selective with their clients. In turn, drugs were often used to cope with transactional sex, and using drugs with clients was associated with a higher vulnerability to violence. Sexual risks seemed to be associated with the contexts of drug using practices, rather than the use of substances per se. On some occasions women would recur to using drugs to cope with transactional sex events. This made women more vulnerable to experiencing violence, and significantly increased sexual health risks [ 60 , , , , , , ].
Providing alternative opportunities e. Love and trust were common in steady relationships. These feelings hindered condom use with partners, and facilitated using condoms with clients among women engaging in transactional sex, as condoms were perceived as a barrier for intimacy. In turn, reduced love and trust made women less likely to use condoms with clients [ , , , , ]. Condoms were used for transactional sex as an emotional barrier and coping mechanism. Following previous research, data from this review suggested that women who wanted to have a baby were likely to engage in condomless sex.
Those who wanted to prevent pregnancy used condoms more consistently [ ]. It is important to acknowledge that these findings can be extrapolated to any other women. It is important to highlight that the direction and role of the factors identified were unclear in most cases. The network of interrelations between factors and outcomes is also imprecise and inconclusive. An explanation for this is that most studies were cross-sectional, and the few longitudinal studies did not focus on exploring the impact of factors on sexual risks over time.
For this reason, the findings presented in this review cannot be considered determinants , but rather factors that are related or not to certain sexual risks. The evidence found is highly heterogeneous due to the extensive methodological differences between studies, and the variety in the samples and other study characteristics, making it difficult to synthesise the data. Even though all papers comprised WHOD, the characteristics of the samples were rather diverse.
For instance, some studies exclusively included incarcerated women, PWID, or women engaging in transactional sex. Data were mainly self-reported, which may lead to recall biases and a potential gap between reported and actual behaviour [ , ]. It also suggests that women might have under-reported sexual risks leading to biased outcomes. It is then clear that merging all data together is not only challenging, but it is important to be cautious and not interpret the findings as from a homogeneous dataset.
Future research should include longitudinal and experimental studies, in order to explore the direction of the impact of the identified factors on sexual risks, and compare such findings between different groups e. Also, future studies should carefully approach and address research biases e.
On the other hand, it remains unknown whether quantitative papers reported all null findings. Taking these critiques on board, and following the example of some of the papers included in this review, future research should aim at reporting non-significant results. This could help reach a higher consistency and robustness in the evidence available, as well as to determine which areas need further investigation.
The lack of strong theoretical and methodological approaches in the included papers is concerning. Theories are a systematic way of understanding behaviour and different phenomenon, and serve as tools to explain and predict events or situations by specifying relations among factors. They are key to understand the determinants of health and factors associated with sexual risks, as well as to suggest ways to develop effective behaviour change methods [ 30 , , ]. Most research included in this review has been conducted in developed western countries, where the social perspectives on sexuality and gender dynamics might differ vastly from those ones in other countries and cultures.
Punitive laws, policies and practices violating human rights e. None of the publications included explored the use of female condoms or other barrier methods such as the dental dam, nor the use of pre-exposure prophylaxis PrEP. All research included in this review exclusively appraised the use of male condoms. Even though research on the female condom and dental dam is limited, research has highlighted the potential benefits of these barrier methods [ , , , , , ].
Likewise, advances on the use of pre-exposure prophylaxis PrEP seem to be promising in preventing HIV [ , , ]. Synthesising the data presented several challenges that highlighted the lack of consistency in the methodology and outcomes of the included studies. This review was limited by only including English language papers, self-reporting and reporting biases, and the potential incomplete retrieval of relevant research.
The search may have limited the findings as structural factors, partly because policy documents were not purposively searched for. As cited by McMillan et al. A need for differentiation from sex work has been asserted on the grounds that the sexual transactions are a financial necessity and a desperate measure, or are opportunistic and temporary responses to limited income options, or that they are non-commercial as the exchange enacts symbolic rather than financial functions. Not using condoms for all sexual encounters throughout the whole sexual act, or for any sexual activity.
Using condoms for all sexual encounters throughout the whole sexual act, or for any sexual activity. This work was supported by a Ph. Studentship granted to L. Medina-Perucha by the University of Bath. The authors would like to thank the contributions of Prof Julie Barnett to the development of this paper. We are thankful for feedback from the delegates. This article does not contain any studies with human participants or animals performed by any of the authors. Skip to main content Skip to sections. Advertisement Hide. Download PDF. Authors Authors and affiliations L. Medina-Perucha H.
Family J. Scott S. Chapman C. Open Access. First Online: 02 August Study authors were contacted when there was no full-text access, and to identify potential additional studies. The search and study selection were performed by the first author LMP. Any disagreements regarding the inclusion or exclusion of papers were resolved over the meetings. Open image in new window. Study Characteristics A total of 30 peer-reviewed articles were included in this review. There were 23 quantitative studies and seven qualitative studies [ 53 , 54 , 55 , 56 , 57 , 58 , 59 ].
Seventeen publications were women-only studies [ 51 , 52 , 57 , 58 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 ]. All participants in the included studies were using drugs. This section has been organised by sexual risk outcomes. Socio-demographics Age There seemed to be a relationship between age and condom use. Risk Awareness and Perception of Control Condom use was predicted when women perceived control over condom use, and using a condom made women feel responsible [ 65 ]. Number of Sexual Partners The number of male sexual partners was positively correlated with a lack of condom use [ 62 ].
Substance Use Alcohol Use Using alcohol was associated with a decreased frequency in condom use [ 62 , 65 ]. Transactional Sex There were no significant differences in condom use between women engaging in transactional sex and those who did not [ 67 ]. Preferences, Negotiation and Availability of Condoms Condom use was facilitated when it was discussed, and especially when women were more willing to use condoms.
Drug Use There were very few and robust data on the relationship between drug use and the type and characteristics of sexual partners. Morris M, Kretzschmar M. Similarly, promising mathematical models of the dynamics of the spread of HIV infection require data on a wide range of sexual behaviors; these data currently are not available. Service S, Blower SM. London: International African Institute; Reliability and validity of a brief measure of sensation seeking.
Socio-demographics Age There was conflicting evidence regarding the relationship between age and transactional sex. Gender Roles and Gender-Based Violence Socially constructed gender roles and power dynamics in which men are dominant over women were associated with engaging in transactional sex [ 56 ]. Substance Use Drug Use Injecting drug use was associated with engaging in transactional sex [ 50 , 66 , 67 , 76 , 78 ]. Socio-demographics Ethnicity and Country of Origin Among women engaging in transactional sex in Mexico, those born in the US who spoke English were more likely to report sexual violence [ 71 ].
Transactional Sex Selling sex made women particularly vulnerable to sexual and physical violence, and consequently increased sexual health risks [ 54 , 56 , 57 , 59 ]. Socio-demographics Age According to the data of one of the included papers [ 66 ], women who initiated sex at a younger age were more likely to have multiple sexual partners. Gender Roles and Gender-Based Violence No significant associations were found between recent partner violence and having had sex with more than one partner in the past year [ 64 ].
Substance Use Drug Use Having multiple sexual partners was significantly correlated with higher drug injecting [ 50 , 66 ] and crack use [ 76 ]. Socio-demographics Ethnicity White women were more likely than Black women to have a sexual partner who injected drugs [ 50 ]. Transactional Sex Selling sex was associated with women being more likely to have sex with strangers or a friend, rather than with a boyfriend or husband [ 67 ]. Number of Sexual Partners The evidence available indicated that the number of male sexual partners was positively correlated with the number of needle-sharing partners [ 62 ].
Gender Roles and Gender-Based Violence There were no significant associations between recent partner violence, and having sex with a PWID, having sex with a partner who had sex with someone else in the past year, and having sex with a partner who had an STI in the past year [ 64 ]. Substance Use Drug Use There were very few and robust data on the relationship between drug use and the type and characteristics of sexual partners. Socio-demographics Ethnicity Compared to Black women, White women reported higher use of drugs before and after transactional sex, and higher use of injecting drugs with steady and casual partners [ 69 ].
Gender Roles and Gender-Based Violence A non-significant relationship was found between experiencing sexual violence and an increased likelihood of using drugs with clients, among women involved in transactional sex [ 71 ]. Aim 1: Factors Associated with Sexual Risks A wide range of factors, from socio-demographic characteristics to social contexts of violence and power dynamics between women and men, were found to be associated with sexual risks among WHOD.
Gender-Based Violence: Power Inequities and Human Rights Despite the ambiguity of the findings, the evidence between experiencing violence and sexual risks was found to be fairly robust. Transactional Sex: Social Neglect and Structural Violence Contrary to what previous research has suggested [ 98 ], no clear relationship was found between condom use and transactional sex with either clients or non-clients in the quantitative studies. Substance Use: Contextual Factors of Drug and Alcohol Use and Sexual Risks Among women who did not engage in transactional sex, the relationship between condom use and substance use was unclear.
Aim 2: The Nature and Quality of the Evidence Study Design and Methodology It is important to highlight that the direction and role of the factors identified were unclear in most cases. Use of Theory and Scope of the Research The lack of strong theoretical and methodological approaches in the included papers is concerning.
Beyond the Male Condom and HIV None of the publications included explored the use of female condoms or other barrier methods such as the dental dam, nor the use of pre-exposure prophylaxis PrEP. Acknowledgements This work was supported by a Ph. Compliance with Ethical Standards Conflict of interest The authors declare that they have no conflict of interest. Human and Animal Rights This article does not contain any studies with human participants or animals performed by any of the authors.
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