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Transactional sex, the casual exchange of sexual favors for money or gifts, has been associated with negative outcomes and health risks, particularly among youth. This global review of the evidence explores trends of buying and selling sex among the general population of male and female youth across 28 countries. It compares the differences and similarities in preva- lence rates between genders (male versus female), sex trading activities (selling versus buying), and country income groups (high-income versus low- and middle-income countries) and examines the relationships and situations surrounding transac- tional sex, and its correlates. The screening of reports resulted in the inclusion of 37 manuscripts (N = 120,447 participants), involving peer review and grey literature describing longitudinal and cross-sectional research across 7 high-income and 21 low- and middle-income countries. The review of prevalence rates suggests relatively low rates of transactional sex in high- income countries (with selling and buying rates below 10% in all countries) and relatively high, although varying rates, in low- and middle-income countries (with selling and buying rates of 60% or higher in seven countries). Gender disaggregated data suggests that boys are more likely than girls to sell sex in high-income countries while the opposite seems to be true in low- and middle-income countries. The findings suggest that initial contact between sellers and buyers is most often estab- lished through friends, acquaintances, and dating websites. The age of onset is around 15 years, many sellers and buyers already know each other before trading sex, and they are often of a similar age. Money is the most commonly used form of compensation. Correlates of selling sex include involvement in other risky sexual behaviors, substance use, infection with sexually transmitted diseases, mental health problems, family break-up, and a history of victimization. No or mixed relations have been found with socioeconomic and educational status. The correlates of buying sex include promiscuity, substance use, violence perpetration and, to some extent, higher socioeconomic status. Recommendations for future research are discussed. Keywords Transactional sex · Buying sex · Selling sex · Youth · Adolescents Introduction Transactional sex among youth, or the casual exchange * Maria Krisch of sexual favors for money or gifts, has only recently firstname.lastname@example.org become a focus of research. While it shares many char- Margit Averdijk acteristics with commercial prostitution, it differs in a email@example.com number of ways. Whereas in many countries, commercial Sara Valdebenito prostitution is considered a profession, transactional sex is firstname.lastname@example.org mostly viewed as the informal trading of sex, experimen- Manuel Eisner tal, and of low frequency (Fredlund et al. 2013; Svedin email@example.com and Priebe 2007). In addition, while for many juvenile 1 sex workers involvement in the commercial sex market Institute of Criminology, University of Cambridge, is a main source of income, transactional sex generally Cambridge, UK 2 supplements other income sources (Jewkes et al. 2012b; Jacobs Center for Productive Youth Development, University Fredlund et al. 2013). Different from many commercial of Zurich, Zurich, Switzerland Vol.:(0123456789) 1 3 116 Adolescent Research Review (2019) 4:115–134 sex workers, young people who engage in transactional Prior reviews of youth in transactional sex have studied sex also report that they are selective about their custom- specific sub-populations, often with a focus on one gen- ers and the sexual acts that they perform, and that they do der (male or female) and one sex trading activity (buying not view themselves as sex workers (Kaufman and Stavrou or selling), in a limited number of countries. Examples 2004; Luke and Kurz 2002; Nnko et al. 2001). As a result include a summary of the literature on the prevalence of of these differences, public health research typically dif- HIV among men who engage in transactional sex (Olden- ferentiates transactional sex from commercial prostitution. burg et al. 2014), a systematic review of sexually exploited Transactional sex has been linked to various maladap- boys (Moynihan et al. 2018), a review of the risk factors of tive outcomes and health risks, including sexually trans- selling sex among women in humanitarian crises (Formson mitted diseases, physical or sexual violence, delinquency, and Hilhorst 2016), and a review of studies on transactional substance abuse, psychological problems, and physi- sexual relations in African countries (Luke and Kurz 2002; cal illnesses, although the majority of studies has been Stoebenau et al. 2016). Prior reviews fall short, however, cross-sectional and therefore unable to establish causality in analyzing the differences and commonalities of transac- (Dunkle et al. 2007; Haley et al. 2004; Svedin and Priebe tional sexual relations among male and female youth as they 2007). Youth seem to be particularly vulnerable as they engage in both sides of the sex trade (buying and selling). are more susceptible to risk-taking behavior, including To date, there is also no review that compares and contrasts unprotected sex, than adults. As suggested by previous patterns of transactional sexual relationships in different research, sexual risk-taking along with substance use and regions of the world. conduct problems, are the main explanatory factors of morbidity and mortality among young people (Mustan- ski et al. 2013). One reason might be that youth have not The Current Study yet reached cognitive maturity and often lack the abil- ity to assess long-term consequences, potentially lead- This study fills existing gaps by summarizing the evidence ing to negative effects on their physical and emotional base on transactional sex among general population samples health (Saphira and Oliver 2002) which can extend into of male and female youth around the world and compar- later life. In addition, transactional sex may have nega- ing the differences and similarities between genders (male tive consequences for youth sellers as it has been linked versus female), sex trading activities (selling versus buy- to power imbalances with buyers, most notably large age ing), and country income groups as defined by the World differences (with sellers being much younger than buyers) Bank (2017) (high-income versus low- and middle-income and differences in economic resources (with sellers having countries). This review also examines the commonalities in much less access to these than buyers) (Luke 2003, 2005). the contexts in which transactional sex occurs and discusses Recent research suggests, however, that transactional sex frequently cited risk factors linked to buying and selling sex. also occurs to a large extent between same-aged peers, and Understanding transactional sex and its correlated risks, may that both genders report selling and buying sex (Lavoie guide practitioners to develop early intervention programs et al. 2010; Fredlund et al. 2013; Svedin and Priebe 2007; to prevent the consequences of these practices. At the same Choudhry et al. 2014). time, the analysis of its specific impact on different genders As official statistics on the prevalence of transactional sex and cultures would contribute to specify effective tailored among youth are lacking, researchers have used self-report responses for these highly vulnerable groups. studies to gauge the extent of the phenomenon. Although several of these have focused on high-risk populations (e.g., homeless and runaway youth, delinquent youth, substance Methods users, and victims of abuse; Edwards et al. 2006a; Haley et al. 2004), the past decade has seen an increasing number Search Strategies of studies that have examined involvement in transactional sex in the general population of youth. The extent to which The authors conducted electronic searches in three com- young people are involved in transactional sex may differ prehensive databases (e.g., Web of Science, PsychInfo, and across the geographical regions of the world. Individual Google Scholar) for all empirical studies on transactional sex studies have documented varying rates, but there is a lim- published up to May 28th, 2017. These extensive searches ited knowledge of large-scale variation across geographic were conducted to identify and retrieve an exhaustive col- regions. An improved understanding of the global scale as lection of empirical studies, thus minimizing the possibility well as variations at the national and regional levels can help of publication bias. Electronic searches were complemented to identify gaps in knowledge and support future prevention with a revision of the list of references of retrieved articles. and intervention research. All references were scanned to find additional studies. 1 3 Adolescent Research Review (2019) 4:115–134 117 Published and unpublished studies from any country, sex, correlations). A senior member of the team reviewed the whose title and abstract were written in English, were annotated PDFs and coding spreadsheets to ensure that data explored. Searches were conducted using a selected set of was accurately recorded. When the information reported in keywords, in various different combinations (“adolescen*”, the manuscript was unclear or contentious, senior members “youth*”, “boy”, “girl”, “teen”, “young”, “juvenile”), (“sell* of the team were consulted for further input on what should sex”, “buy* sex”, “transactional sex”). The searches were be recorded. 2 contentious cases were identified and dis- combined with the use of Boolean terms as appropriate (e.g., cussed among authors. Upon closer investigation, these two “OR”, “AND”). cases included the same data and only one of the articles was included (Moore et al. 2007). Mendely software was used to Criteria for Inclusion or Exclusion manage references, citations, and documents. For the purpose of the present review, included studies met the following criteria. First, sources explored for inclusion Results were book chapters (e.g., Lee and Shek 2014), journal arti- cles, government and NGO studies (e.g., De Graaf et al. Initial online searches yielded over 7020 hits. After remov- 2005), and academic PhD theses (e.g., Choudhry 2015). Sec- ing duplicates and assessing eligibility, 37 studies were ond, a number of relevant studies written in languages other found that matched the inclusion criteria of this review. than English were identified by going through the reference Included studies were published between January 1, 1990 lists of articles. Relevant information in these articles was and May 28, 2017. translated and included in the analysis (Mossige 2001; De Table 1 lists all 37 studies. The first studies were con- Graaf et al. 2005). Third, since the aim of this review was to ducted in the 1990s (five studies), but the majority was con- examine a general population sample of youth such as those ducted after 2000 (32 studies). Two pairs of studies were in schools, young people from high-risk populations were based on the same sample (Choudhry 2015; Choudhry et al. excluded from this review. For instance, manuscripts report- 2014; Fredlund et al. 2013; Svensson et al. 2013) and three ing transactional sex among AIDS-orphaned and AIDS- studies comprised findings from separate waves in a pro- affected adolescents (e.g., Cluver et al. 2013) or young spective design (Lee and Shek 2013, 2014; Lee et al. 2016). people living on the street (e.g., Mcclair et al. 2017) were Thus, the total number of unique studies was 33. Combined, excluded from this study. Fourth, the review follows the all unique studies that reported sample size data (27 out of United Nations’ definition (2013) of youth as the age cohort 33) had a sample size of 120,447 participants. The sample 15 to 24 (e.g., Atwood et al. 2012). Any relevant studies size ranged from 80 (Nyanzi et al. 2001) to 13,294 (Edwards that fitted within the United Nations’ definition of youth but et al. 2006b) and was on average 3011 participants. Almost diverged from the lower or upper age limit by 2 years (e.g., all studies were cross-sectional. Only two longitudinal stud- 12 years and 26 years) were also included in this review ies were found (Jewkes et al. 2016; Lee et al. 2016). Data (e.g., Dunkle et al. 2007). Studies reporting transactional collection methods varied, with most studies administer- sex among older samples were excluded from the study ing self-completed, paper-based questionnaires, and others (e.g., Magni et al. 2015). Finally, any qualitative studies online questionnaires, audio-computer assisted question- were excluded because of this study’s focus on statistical naires, or structured face-to-face interviews using standard- information (e.g., Eller 2016; Song and Morash 2016). ized questions. Out of all 37 studies, 19 were conducted in Sub-Saharan Africa, four in North America, 11 in Western Data Extraction Europe, and three in Asia. A protocol for data extraction was defined by the first author Measurement and agreed with the other authors. Data were extracted from full-text articles by the first author and reviewed by a sen- No standardized instrument currently exists for measuring ior member of the team. Any disagreements were discussed transactional sex. Items used in the included studies typically among the authors. Data extracted was annotated in PDF referred to accepting money or gifts for sexual favors (sell- versions of articles and recorded in a spreadsheet. Extracted ing sex) and giving money or gifts for sexual favors (buying data included characteristics of the studies (e.g., publication sex). The types of gifts, such as drugs, cell phones, shelter, year, country of the sample, size of the sample, methodolog- and food, were sometimes, but not always, specified in the ical design, reporting period, type of transactional sex stud- items. In this article, transactional sex is defined as casual ied—buying versus selling sex), characteristics of partici- sex between two people that is motivated by the expectation pants (e.g., sex, nationality, age), and statistical outputs (e.g., to receive material rewards in exchange for sexual favors. prevalence rates for buying and selling sex disaggregated by The reference period was usually the past 12 months or 1 3 118 Adolescent Research Review (2019) 4:115–134 Table 1 Studies on transactional sex with general population samples of youth Source Site Sample size Age Gender Activity Study design Reference period Atwood et al. Liberia (urban) 714 14–17 years Female and male Selling and Cross-sectional Lifetime (2012) buying Betzer et al. Germany (urban) 4386 24.4 years on Female and male Selling Cross-sectional − (2015) average Carolina Popula- USA − 18–26 years − Selling Cross-sectional − tion Center (2003) Chatterji et al. Kenya 3170 15–24 years Female and male Selling and Cross-sectional Last 12 months (2005) buying Zambia 3592 15–19 years and Female and male Selling and Cross-sectional Last 12 months 20–24 years buying Zimbabwe 1533 15–19 years and Female and male Selling and Cross-sectional Last 12 months 20–24 years buying Benin 1790 15–19 years and Female and male Selling and Cross-sectional Last 12 months 20–24 years buying Burkina Faso 2301 15–19 years and Female and male Selling and Cross-sectional Last 12 months 20–24 years buying Central African 2297 15–19 years and Female and male Selling and Cross-sectional Last 12 months Republic 20–24 years buying Chad 2753 15–19 years and Female and male Selling and Cross-sectional Last 12 months 20–24 years buying Guinea 2290 15–19 years and Female and male Selling and Cross-sectional Last 12 months 20–24 years buying Mali 3244 15–19 years and Female and male Selling and Cross-sectional Last 12 months 20–24 years buying Niger 2759 15–19 years and Female and male Selling and Cross-sectional Last 12 months 20–24 years buying Nigeria 2395 15–19 years and Female and male Selling and Cross-sectional Last 12 months 20–24 years buying Togo 3332 15–19 years and Female and male Selling and Cross-sectional Last 12 months 20–24 years buying Choudhry (2015) Uganda (urban) 1954 23 years on Female and male Selling and Cross-sectional Lifetime average; buying majority aged 20–24 years Choudhry et al. Uganda (urban) 1954 ≤ 24 years (72%) Female and male Selling and Cross-sectional Lifetime (2014) and > 24 years buying (28%) Cottler et al. USA − − Female and male Selling Cross-sectional Lifetime (1990) de Graaf et al. Netherlands 4821 12–25 years Female and male Selling and Cross-sectional Lifetime (2005) buying Dunkle et al. South Africa 1288 15–26 years Male Selling and Cross-sectional Lifetime (2007) (rural) buying Edwards et al. USA 13,294 16.2 years on Female and male Selling Cross-sectional Lifetime (2006b) average Fredlund et al. Sweden 3498 18.3 years on Female and male Selling Cross-sectional Lifetime (2013) average Helweg-Larsen Denmark 6203 15–16 years Female and male Selling Cross-sectional − (2003) Jewkes et al. South Africa 1077 15–26 years Female Selling Cross-sectional Lifetime (2012a) Jewkes et al. South Africa 1645 18–24 years Male Buying Cross-sectional Lifetime (2012b) Jewkes et al. South Africa 1370 15–26 years Male Selling and Longitudinal Lifetime (2016) buying 1 3 Adolescent Research Review (2019) 4:115–134 119 Table 1 (continued) Source Site Sample size Age Gender Activity Study design Reference period Komba-Malekela Tanzania (urban) − 14–19 years − Selling − Lifetime and Liljestrom (1994) Lavoie et al. Canada (urban) 815 15–18 years Female and male Selling and Cross-sectional Lifetime (2010) buying Lee and Shek China 3638 13.6 years on Female and male Selling Cross-sectional Lifetime and last (2013) average 12 months Lee and Shek China 3239 15.5 years on Female and male Selling Cross-sectional Last 12 months (2014) average Lee et al. (2016) China 2921 13.6 years on Female and male Selling Longitudinal Lifetime and last average in 12 months (3 2010–2011, waves) 14.7 years on average in 2011–2012, 15.5 years on average in 2012–2013 Machel (2001) Mozambique 182 14–20 years Female Selling Cross-sectional − (urban) Mossige (2001) Norway (urban) 713 18–20 years Female and male Selling Cross-sectional − Meekers and Cameroon − 12–17 years and Female and male Selling and Cross-sectional Lifetime Calvès (1999) 18–22 years buying Moore et al. Burkina Faso 5955 12–19 years Female and male Selling Cross-sectional Last 12 months (2007) Ghana 4430 12–19 years Female and male Selling Cross-sectional Last 12 months Malawi 4031 12–19 years Female and male Selling Cross-sectional Last 12 months Uganda 5112 12–19 years Female and male Selling Cross-sectional Last 12 months Mossige and Norway 4911 18–20 years Female and male Selling Cross-sectional − Abrahamsen (2007) Nyanzi et al. Uganda (rural) 80 12–20 years Female Selling Cross-sectional Lifetime (2001) Okigbo et al. Liberia 439 14–25 years Female Selling Cross-sectional Lifetime (2014) Pedersen and Norway (urban) 10,828 14–17 years Female and male Selling Cross-sectional Last 12 months Hegna (2003) Population Refer- Kenya − 15–19 years Female Selling Cross-sectional Recently ence Bureau Mali − 15–19 years Female Selling Cross-sectional Recently (2001) Uganda − 15–19 years Female Selling Cross-sectional Recently Zambia − 15–19 years Female Selling Cross-sectional Recently Zimbabwe − 15–19 years Female Selling Cross-sectional Recently Ranganathan South Africa 693 13–20 years Female Selling Cross-sectional Lifetime et al. (2016) (rural) Renzaho et al. Uganda 623 13–24 years Female and male Selling Cross-sectional Last 12 months (2017) Svedin and Sweden 4339 18.15 years on Female and male Selling Cross-sectional Lifetime Priebe (2007) average Svensson et al. Sweden − 18.3 years on Female and male Selling Cross-sectional − (2013) average Thorensen Norway − 13–17 years − Selling Cross-sectional Last 12 months (1995) Vejle Amt Denmark 2410 15–16 years Female and male Selling Cross-sectional − (2005) Weiss et al. Nigeria − 16 years or older Female Selling Cross-sectional Lifetime (1996) 1 3 120 Adolescent Research Review (2019) 4:115–134 Table 1 (continued) Source Site Sample size Age Gender Activity Study design Reference period South Africa 259 16–24 years Female Selling Cross-sectional Last 12 months Zembe et al. (peri-urban) (2015) Cited in Svedin and Priebe (2007) Cited in Walle et al. (2012) Cited in Fredlund et al. (2013) Cited in Luke and Kurz (2002) the respondent’s lifetime, but it was not always reported. reported), followed by Canada (4%, lifetime prevalence) and Table 2 provides examples of questionnaire items that have the United States (2.8%, reference period not reported, and been used in existing studies on transactional sex. Although 3.5%, lifetime prevalence), while prevalence rates in other there have been exceptions (e.g., Jewkes et al. 2016), studies high-income countries were lower. have typically used one or two items to measure either sell- With the exception of the study by Lavoie et al. (2010) ing or buying sex. Thirty-five studies reported on selling sex in Canada, which reported that three times as many female and nine studies reported on buying sex (the total number (6%) compared to male (2%) youth had sold sex, prevalence of studies is higher as some studies reported on both). One rates of selling sex were higher among males than females. study measured involvement in transactional sex, but it did Six out of seven studies with data for both, male and female not distinguish between selling and buying (Chatterji et al. youth, reported higher selling rates for males compared to 2005). females, ranging from 1.7% (lifetime) to 2.6% (reference Below, prevalence estimates are presented first. The 37 period not reported) for males and 0.6% (last 12 months) to studies included in this review provide prevalence estimates 2.3% (lifetime) for females. for 28 countries. The results from high-income countries are Only three studies examined buying sex. In the Nether- compared to results from low- and middle-income coun- lands, prevalence rates were 6% for male and 1% for female tries. Next, the situations and relationships surrounding 12- to 25-year-olds. In the United States, a study among transactional sex are described. Differences between coun- female youth showed that 4% had ever bought sex. Finally, try income groups are described where applicable. Subse- Lavoie et al. (2010) reported buying rates of 5% among male quently, research on the correlates of involvement in trans- and 2% among female youth in Canada. actional sex is presented. Low‑ and Middle‑Income Countries Prevalence of Transactional Sex The search identified 22 studies on transactional sex in 21 High‑Income Countries low- and middle-income countries as defined by the World Bank (2017) [e.g., countries with a GNI per capita of $995 The review identified 15 studies with prevalence estimates or less (low-income countries) or between $996 and $12,055 on transactional sex in seven high-income countries as (middle-income country) in 2017]. With the exception of defined by the World Bank (2017) (e.g., countries with a one study in China, all were conducted in Sub-Saharan GNI per capita of $12,056 or higher in 2017). Most stud- Africa. The higher number of studies may be due to the ies (11 out of 15) were conducted in Northern and Western fact that transactional relationships are more widespread in Europe (Norway, Sweden, Denmark, Germany, and Nether- these countries (Manganja et al. 2007; Nyanzi et al. 2001). lands); the remaining four in North America (the USA and Twelve studies used lifetime reference periods, four provided Canada). Six studies used lifetime reference periods, two past-year rates, three studies used more than one reference provided past-year rates, and seven did not report the refer- period (e.g., lifetime, last 12 months, last 4 weeks), and two ence period. Fifteen studies reported on selling sex and three studies did not report a reference period. Twenty-two studies studies reported on buying sex (the total number of studies reported on selling sex while nine studies reported on buying is higher as some studies reported on both). Prevalence esti- sex. Prevalence estimates are provided in Table 4. mates are provided in Table 3. Data suggest that transactional sex is relatively common The results suggest that transactional sex is uncommon among youth in Sub-Saharan Africa. The highest rate for among youth in high-income countries. The highest overall selling sex among female youth was reported in Uganda selling rates among both male and female youth (combined (85%, lifetime prevalence). Particularly high prevalence rates) were reported in Germany (7%, reference period not rates were recorded in six countries, with over 60% of 1 3 Adolescent Research Review (2019) 4:115–134 121 Table 2 Examples of questionnaire items to measure youth involvement in transactional sex Selling sex (transactional sex): “Have you ever accepted money, a gift, or some form of compensation as payment Cottler et al. (1990) for sexual relations?” Buying sex (transactional sex): “Have you ever paid money or given a gift, or otherwise compensated for sexual relations?” Selling sex (transactional sex): “Have you ever had sex with someone because he or she promised to give you Atwood et al. (2012) something that you needed or wanted?” Buying sex (transactional sex): “Have you ever had sex with someone when you promised to give that person something that he or she needed or wanted?” Selling and buying sex – combined measure (transactional sex): “Have you given or received money, gifts, or Chatterji et al. (2005) favors in return for sex at any time within the last 12 months?” Selling sex to a casual main partner (transactional relationship): “Have you ever become involved with a roll-on/ Dunkle et al. (2004) nyasti/makwapheni because he provided you with or you expected that he would provide you with food, cosmet- ics, clothes, transportation, tickets or money for transport, items for children or family such as clothes, food or school fees, woman’s own school or residence fees, somewhere to sleep or cash” Buying sex from a casual main partner (transactional relationship): “Do you believe any of your main partners Dunkle et al. (2007); Jew- became involved with you because they expected you to provide them with, or because you provided them with kes et al. (2012b) food, cosmetics, clothes, transportation, items for children or family, school fees, somewhere to sleep, alcohol or a ‘fun night out’, or cash?” Selling sex to a casual main partner (transactional relationship): “Did you become involved with a main partner because she provided you with or you expected that she would provide you with food, cosmetics, clothes, trans- portation, items for children or family, school fees, somewhere to sleep, alcohol or a ‘fun night out’, or cash?” Selling and buying sex (transactional sex): six questions asking about giving or receiving cash or goods/services in Jewkes et al. (2016) exchange for sex with a main partner, once-off partner or khwapheni (secret on-going partner); each assessment was based on 8 possible transacted items Selling sex (transactional sex): “Have you ever had sexual intercourse with a stranger of either the same or the Lee and Shek (2014) opposite sex for the sake of gaining money or material return (e.g., receiving a cell phone as a gift)?” “During the past 12 months, have you ever had sexual intercourse with a stranger of either the same or the opposite sex for the sake of gaining money or material return (e.g., receiving a cell phone as a gift)?” Selling sex (transactional sex): “Have you ever received money, food, clothing, shelter, school fees, drugs, or liquor Okigbo et al. (2014) in exchange for sex?” Selling sex (transactional sex): “Have you, in the course of the recent 12 months, given sexual favors for payment?” Pedersen and Hegna (2003) Selling sex (transactional sex): ‘‘Did you feel like you had to have sex with [initials] because they gave you Ranganathan et al. (2016) money’’?; ‘‘Did you feel like you had to have sex with [initials] because they gave you things (such as airtime, cell phone, groceries, clothes or shoes, perfume or lotions, make-up, cool-drinks, sweets or chips, CDs, DVDs or videos, alcohol or drugs, flowers, other (specify))’’? Selling sex (transactional sex): “Have you been persuaded to have sex through gifts, money or other favors during Renzaho et al.(2017) the last 12 months?” Selling sex (transactional sex): “When my main partner has given me money, he expects me to do everything that Zembe et al. (2015) he wants me to do.” Selling sex (transactional sex): “Have you ever accepted money, a gift or some other form of compensation as pay- Choudhry et al. (2014) ment for sexual relations?” Buying sex (transactional sex): “Have you ever paid money, or given a gift or otherwise compensated for sexual relations?” female youth reporting that they sold sex: Ghana (74.7%, (Meekers and Calvès 1999) to 85% among 12- to 20-year- last 12 months), Liberia (72%, lifetime), Malawi (80.5%, olds in Uganda (Nyanzi et al. 2001). Few studies exam- last 12 months), Mozambique (63%, reference period not ined lifetime prevalence rates for selling sex among male reported), Tanzania (80%, lifetime), and Uganda (75%, last youth. Among those that did, lifetime rates ranged from 12 months; 85% lifetime). 6.6% among 15- to 26-year-olds in South Africa (Dunkle In contrast to high-income countries, where more males et al. 2007) to 12% among 14- to 17-year-olds in Libe- reported selling sex than females, all six studies that col- ria (Atwood et al. 2012). Compared to these estimates, lected comparative data on selling sex for both sexes the multi-country study by Moore et al. (2007) showed in Sub-Saharan Africa reported higher selling rates for relatively high prevalence rates for some countries (e.g., female compared to male youth. Lifetime prevalence rates Ghana: 33.3%, Uganda: 34.6% for males), but this study for selling sex among female youth in Sub-Saharan Africa used a past-year reference period in a sample of youth who ranged from 5% among 12- to 17-year-olds in Cameroon had been sexually active in the past 12 months. 1 3 122 Adolescent Research Review (2019) 4:115–134 Table 3 Prevalence rates of transactional sex in general population samples of youth in high-income countries Country Selling Buying Selling Buying Selling Buying Source Reference Age (females) (females) (males) (males) (males and (males and period females) females) Canada 6.0% 2.0% 2.0% 5.0% 4.0% 3.0% Lavoie et al. Lifetime 15–18 years (2010) Denmark − − − − 1.0% − Helweg- − 15–16 years Larsen (2003) Denmark − − − − 1.6% − Vejle Amt − 15–16 years (2005) Germany − − − − 7.0% − Betzer et al. − 24.4 years on (2015) average Netherlands 1.0% 1.0% 2.0% 6.0% − − Graaf et al. Lifetime 12–25 years (2005) Norway 0.7% − 2.6% − − − Mossige − 18–20 years (2001) Norway < 1% − 1–3% − − − Mossige and − 18–20 years Abraham- sen (2007) Norway 0.6% − 2.1% − 1.4% − Pedersen Last 12 14–17 years and Hegna months (2003) Norway − − − − 1.3% − Thorensen Last 12 13–17 years (1995) months Sweden − − − − 1.5% − Svensson − 18.3 years on et al. average (2013) Sweden 1.2% − 1.7% − 1.5% − Fredlund Lifetime 18.3 years on et al. average (2013) Sweden 1.0% − 1.8% − 1.4% − Svedin and Lifetime 18.5 years on Priebe average (2007) USA − − − − 2.8% − Carolina − 18–26 years Population Centre (2006) USA 2.0% 4.0% − − − − Cottler et al. Lifetime − (1990) USA 2.3% − − − 3.5% − Edwards Lifetime 16.2 years on et al. average (2006b) Cited in Svedin and Priebe (2007) Cited in Walle et al. (2012) Cited in Fredlund et al. (2013) Only two studies explicitly asked about buying sex There were substantial die ff rences in prevalence estimates among female youth. These found that 6.2% (reference for some studies that were conducted in the same country, period not reported) of female youth in Uganda (Choudhry for example between studies in Liberia (Atwood et al. 2012; et al. 2014) and 8.2% (lifetime) in Liberia (Atwood et al. Okigbo et al. 2014), Malawi (Moore et al. 2007), South 2012) had ever bought sex. Lifetime prevalence rates of Africa (Dunkle et al. 2007; Jewkes et al. 2012a, b; Rangana- buying sex among males ranged from 14% in Cameroon than et al. 2016; Zembe et al. 2015), and Uganda (Choudhry (Meekers and Calvès 1999) and Liberia (Atoowd et al. et al. 2014; Moore et al. 2007; Nyanzi et al. 2001; Popula- 2012) to 60.4% in South Africa (Jewkes et al. 2012b). tion Reference Bureau 2001). These differences are due to 1 3 Adolescent Research Review (2019) 4:115–134 123 1 3 Table 4 Prevalence rates of transactional sex in general population samples of youth in low- and middle-income countries Country Selling (females) Buying (females) Selling (males) Buying (males) Selling (males Buying Source Reference period Age and females) (males and females) Benin 13.8% (combined rate) − − − − Chatterji et al. Last 12 months 15–19 years (2005) Benin 4.1% (combined rate) 29.8% (combined rate) − − Chatterji et al. Last 12 months 20–24 years (2005) Burkina Faso 8.3% (combined rate) 26.1% (combined rate) − − Chatterji et al. Last 12 months 15–19 years (2005) Burkina Faso 1.2% (combined rate) 22.3% (combined rate) − − Chatterji et al. Last 12 months 20–24 years (2005) Burkina Faso 35.9% − 5.1% − − − Moore et al. Last 12 months 12–19 years (2007) Cameroon 5.0% − − 14.0% − − Meekers and Lifetime 12–17 years Calvès (1999) Cameroon 15.0% − − 30.0% − − Meekers and Lifetime 18–22 years Calvès (1999) Central African 6.8% (combined rate) 17.9% (combined rate) − − Chatterji et al. Last 4 weeks 15–19 years Republic (2005) Central African 5.8% (combined rate) 22.3% (combined rate) − − Chatterji et al. Last 4 weeks 20–24 years Republic (2005) Chad 5.3% (combined rate) 48.4% (combined rate) Chatterji et al. Last 12 months 15–19 years (2005) Chad 2.4% (combined rate) 31.7% (combined rate) − − Chatterji et al. Last 12 months 20–24 years (2005) China − − − − 0.4% (lifetime), − Lee and Shek Lifetime and last 13.6 years on aver- 0.4% (last 12 (2013) 12 months age months) China − − − − 0.6% − Lee and Shek Last 12 months 15.5 years on aver- (2014) age China − − − − 0.2% in 2010– − Lee et al. (2016) Lifetime and last 13.6 years on aver- 2011, 0.4% in 12 months age in 2010– 2011–2012, 2011, 14.7 years 0.6% in on average in 2012–2013 2011–2012, (lifetime) 0.2% 15.5 years in 2010–2011, on average in 0.4% in 2011– 2012–2013 2012, 0.4% in 2012–2013 (last 12 months) Ghana 74.7% − 33.3% − − − Moore et al. Last 12 months 12–19 years (2007) 124 Adolescent Research Review (2019) 4:115–134 1 3 Table 4 (continued) Country Selling (females) Buying (females) Selling (males) Buying (males) Selling (males Buying Source Reference period Age and females) (males and females) Guinea 6.6% (combined rate) 10.3% (combined rate) − − Chatterji et al. Last 12 months 15–19 years (2005) Guinea 4.6% (combined rate) 5.5% (combined rate) − − Chatterji et al. Last 12 months 20–24 years (2005) Kenya 13.5% (combined rate) 17.6% (combined rate) − − Chatterji et al. Last 12 months 15–19 years (2005) Kenya 7.9% (combined rate) 20.9% (combined rate) − − Chatterji et al. Last 12 months 20–24 years (2005) Kenya 21.0% − − − Population Refer- recently 15–19 years − − ence Bureau (2001) Liberia 13% 8% 12% 14% 17% (combined rate) Atwood et al. Lifetime 14–17 years (2012) Liberia 72.0% − − − − − Okigbo et al. Lifetime 14–25 years (2014) Malawi 80.5% − 9.3% − − − Moore et al. Last 12 months 12–19 years (2007) Mali 13.2% (combined rate) 21.1% (combined rate) − − Chatterji et al. Last 12 months 15–19 years (2005) Mali 8.0% (combined rate) 23.6% (combined rate) − − Chatterji et al. Last 12 months 20–24 years (2005) Mali 26.0% − − − − − Population Refer- Recently 15–19 years ence Bureau (2001) Mozambique 63.0% − − − − − Machel (2001) − 14–20 years Niger 2.0% (combined rate) 40.1% (combined rate) − − Chatterji et al. Last 12 months 15–19 years (2005) Niger 2.2% (combined rate) 21.0% (combined rate) − − Chatterji et al. Last 12 months 20–24 years (2005) Nigeria 13.0% (combined rate) 26.8% (combined rate) − − Chatterji et al. Last 12 months 15–19 years (2005) Nigeria 8.5% (combined rate) 17.2% (combined rate) − − Chatterji et al. Last 12 months 20–24 years (2005) Nigeria 18.0% − − − − − Weiss et al. Lifetime ≥ 16 years (1996) South Africa − − 6.6% 17.7% − − Dunkle et al. Lifetime 15–26 years (2007) Adolescent Research Review (2019) 4:115–134 125 1 3 Table 4 (continued) Country Selling (females) Buying (females) Selling (males) Buying (males) Selling (males Buying Source Reference period Age and females) (males and females) South Africa 8.7% − − − − Jewkes et al. Lifetime 15–26 years (2012a) South Africa − − − 60.4% − − Jewkes et al. Lifetime 18–24 years (2012b) South Africa − − 22% (combined rate) − − Jewkes et al. Lifetime 15–26 years (2016) South Africa 14% − − − − Ranganathan Lifetime 13–20 years et al. 2016 South Africa 42% − − − − − Zembe et al. 2015 Last 12 months 12–24 years Tanzania 80.0% − − − − − Komba-Malekela Lifetime 14–19 years and Liljestrom (1994) Togo 9.3% (combined rate) 14.3% (combined rate) − − Chatterji et al. Last 12 months 15–19 years (2005) Togo 3.3% (combined rate) 12.4% (combined rate) − − Chatterji et al. Last 12 months 20–24 years (2005) Uganda 15.2% 6.2% 10.1% 22.7% 25.4% − Choudhry et al. Lifetime ≤ 24 years (77.2%) (2014) and > 24 years (22.8%) Uganda 15.2% 6.2% 10.1% 22.7% 12.5% 14.9% Choudhry (2015) − − Uganda 75.0% − 34.6% − − − Moore et al. Last 12 months 12–19 years (2007) Uganda 85.0% − − − − − Nyanzi et al. Lifetime 12–20 years (2001) Uganda 31.0% − − − − − Population Refer- Recently 15–19 years ence Bureau (2001) Uganda 7.4% (combined rate) − − − Renzaho et al. Last 12 months 13–24 years Zambia 26.6% (combined rate) 40.0% (combined rate) − − Chatterji et al. Last 12 months 15–19 years (2005) Zambia 12.3% (combined rate) 34.3% (combined rate) − − Chatterji et al. Last 12 months 20–24 years (2005) Zambia 38.0% − − − − − Population Refer- Recently 15–19 years ence Bureau (2001) Zimbabwe 7.3% (combined rate) − − − − Chatterji et al. Last 4 weeks 15–19 years (2005) 126 Adolescent Research Review (2019) 4:115–134 different item wordings, reference periods, sampling strate- gies, and timing. There were also large differences in prevalence rates between countries in Sub-Saharan Africa. Although these may be due to different sampling strategies and items, a cross-national study that used comparable methods across 12 countries in Sub-Saharan Africa (Chatterji et al. 2005; Rutstein and Rojas 2006) found large variations in preva- lence rates. The rates reported for Sub-Saharan Africa also differed from those in a longitudinal study in China, where the combined lifetime prevalence for selling sex among females and males was relatively low at 0.2% (wave one, last 12 months), 0.4% (wave two, last 12 months) and 0.6% (wave three, last 12 months) among a sample of high-school students (Lee et al. 2016). One study suggested that there might be differences in prevalence rates among age groups that fall within the UN definition of youth. According to one study that compared aged groups in various countries in Sub-Saharan Africa (Chatterji et al. 2005), 15- to 19-year- olds were more likely to engage in transactional sex than 20- to 24-year-olds. Situations and Relationships Surrounding Transactional Sex The included studies were reviewed regarding the situations and relationships in which transactional sex occurred. Unfor- tunately, relatively few studies provided such information, making generalizations difficult. This section describes the characteristics on which there exists at least some evidence (e.g., mentioned in two or more studies). These include ways of establishing initial contact with buyers, forms of com- pensation, the age of onset, as well as characteristics of sex partners. Initial Contact The most common way in which sellers and buyers initi- ate contact appears to be through friends and acquaintances and, increasingly, online. In Sweden, both boys (35%) and girls (30%) were most likely to meet buyers via friends and acquaintances (Svedin and Priebe 2007). According to a Cana- dian study, over 90% of transactional sex happened between friends and acquaintances (Lavoie et al. 2010). Across Sub- Saharan Africa, male peers often act as intermediaries between female sellers and male buyers because of the social norm that men should start explicit sexual negotiations (Nnko and Pool 1997; WHO 1992). Dating websites are also a common way to initiate sexual relationships in some high-income coun- tries, but it is unknown whether similar patterns hold for Sub- Saharan Africa. For instance, 23% of American and 57% of Swedish youth engaging in transactional sex reported that their 1 3 Table 4 (continued) Country Selling (females) Buying (females) Selling (males) Buying (males) Selling (males Buying Source Reference period Age and females) (males and females) Zimbabwe 4.1% (combined rate) − − − − Chatterji et al. Last 4 weeks 20–24 years (2005) Zimbabwe 13.0% − − − − Population Refer- Recently 15–19 years ence Bureau (2001) Cited in Svedin and Priebe (2007) Cited in Luke and Kurz (2002) The prevalence rate represents the rate among the sample of people that replied to the transactional sex question (n = 714) Adolescent Research Review (2019) 4:115–134 127 initial contact with prospective buyers was online (Fredlund Correlates of Transactional Sex et al. 2013; Curtis et al. 2008). Sexual Behavior Types of Compensation Findings suggest that youth involved in selling sex are more Money seems to be the most common form of compensation. promiscuous, have an earlier sexual debut, and are more Across four countries in Sub-Saharan Africa, 93% or more of likely to consume pornographic content. Studies in different female youth involved in transactional sex reported that they regions of the world have found a significant link between received money for sexual activities, followed by clothes, selling sex and having a higher number of sexual partners jewelry, and cosmetics (Moore et al. 2007). Similar findings (e.g., Betzer et al. 2015 for Germany; Svedin and Priebe were reported in a South African study among male buyers 2007 for Sweden; Pedersen and Hegna 2003 for Norway; of sex, where half reported exchanging cash for sexual favors Edwards et al. 2006b for the USA; Atwood et al. 2012 for rather than other types of compensation (Jewkes et al. 2012b). Liberia; Dunkle et al. 2007 for South Africa; and; Moore In Sweden, the majority of youth reported receiving money et al. 2007 for Uganda). However, a study in Ghana found a as a payment for sexual activities (Svedin and Priebe 2007; significant relation between selling sex and a lower number Fredlund et al. 2013). In contrast to teenagers in Sub-Saharan of sexual partners (Moore et al. 2007). The link between Africa, however, Swedish youth also frequently received alco- buying sex and a higher number of sexual partners has not hol and cigarettes (24%) or drugs (20%) in exchange for sexual been systematically studied. favors (Fredlund et al. 2013). Early sexual debut has also been associated with selling sex (Lavoie et al. 2010; Pedersen and Hegna 2003; Okigbo Age of Onset et al. 2014; Svedin and Priebe 2007). In Sweden, the aver- age age of first intercourse for youth aged 14 to 18 who The evidence on the age of onset is still limited, but existing had sold sex was 14.4 years, which was significantly lower research from high-income countries suggests that the major- than for those who had not sold sex (15.6 years) (Svedin ity of youth was between 13 and 15 years old when they first and Priebe 2007). While this study did not find gender dif- engaged in transactional sex. For example, in a Canadian study ferences, a Norwegian study reported that the association of adolescents aged 15 to 18, 57% of buyers were between between selling sex and debut age was stronger in girls than 14 and 15 years old, while 63% of sellers were aged 13 to boys (Pedersen and Hegna 2003). It is unknown whether the 15 years (Lavoie et al. 2010). Similarly, in a Swedish study, same pattern holds for buying sex. the mean age of onset among boys and girls who received sex Finally, the consumption of pornographic content or the for money or gifts was 15.6 years (Svedin and Priebe 2007). It observation of sexualized activities has been associated with is unclear whether this age pattern holds in low- and middle- the likelihood of selling sex. In Sweden, boys and girls who income countries. had sold sex watched online pornography more frequently than those who had not sold sex: 38% of boys who had sold Characteristics of Sex Partners sex watched pornography every day as compared to 9% in the reference group (Svedin and Priebe 2007). This study Studies across various countries have found that less than a also found some gender differences in the type of porn quarter of girls who had sold sex had partners that were more being watched. Boys who had sold sex were more likely to than 10 years older than themselves (Luke and Kurz 2002; watch porn involving violence, force, animals, and children Nnko et al. 2001; Gregson et al. 2002; Görgen et al. 1998; compared to boys who had not sold sex, but the groups did Kelly et al. 2003; Kekovole et al. 1997; Lavoie et al. 2010; not differ in their consumption of ordinary porn (e.g., non- Chatterji et al. 2005; Matasha et al. 1998; Kaufman and Stav- violent sex between adults). Girls who had sold sex reported rou 2004; Nyanzi et al. 2001). For example, Svedin and Priebe to have watched both ordinary and deviant types of pornog- (2007) reported that about half of all buyers were of a simi- raphy more often than girls who had not sold sex. In Can- lar age as the sellers (between 15 and 25 years old), whereas ada, Lavoie et al. (2010) examined the association between roughly one-third of buyers was aged 26–35 years, and the transactional sex and promiscuity—measured through the remainder was older than 36 years. observation of participation in nine sexualized social activi- ties (these included wet T-shirt contests, striptease, same-sex kissing, imitation of fellatio with an object, dance contests in which people mime sexual positions, fellatio contests, group sex, and group masturbation). They found that while promiscuity was also significantly associated with buying sex for both genders, it was not linked to selling sex. 1 3 128 Adolescent Research Review (2019) 4:115–134 Substance Use risk for sexually transmitted diseases compared to those who exchanged sex but did not have alcohol problems. It is The use of legal and illegal substances has been widely unknown whether this pattern holds for youth who buy sex. shown to be associated with selling and buying sex (Betzer Youth who sell sex also display an elevated risk of mental et al. 2015; Edwards et al. 2006b; Svedin and Priebe 2007; health issues and depression (Choudhry et al. 2014; Edwards Choudhry et al. 2014; Dunkle et al. 2007; Pedersen and et al. 2006b; Reid and Piquero 2014; Pedersen and Hegna Hegna 2003; Okigbo et al. 2014; Lee and Shek 2013). For 2003; Svedin and Priebe 2007). In a Swedish study, more example, compared to other young people, American youth than half of female youth who sell sex reported that they felt who had sold sex were significantly more likely to have ever that ‘everything was a struggle,’ had troubles sleeping, and consumed marijuana (54% vs. 35%), cocaine (24% vs. 4%), felt unhappy, miserable, depressed, tied up, or tense (Svedin injection drugs (11% vs. less than 1%), and other illicit drugs and Priebe 2007). Similarly, 22% of male and female sellers (30% vs. 10%) (Edwards et al. 2006b). of transactional sex in an American study reported that they In addition, studies in Sweden, Norway, and Liberia felt depressed, compared to 11% of youth who did not sell found strong correlations between a higher frequency of sex (Edwards et al. 2006b). This association was not studied alcohol consumption and selling sex for both girls and boys for youth who buy sex. (Svedin and Priebe 2007; Pedersen and Hegna 2003; Okigbo et al. 2014). In Liberia, 30.5% of girls who had ever engaged Family Characteristics in transactional sex reported daily use of alcohol, compared to 13.1% in the reference group (Okigbo et al. 2014). How- Alcohol abuse at home can increase the likelihood of sell- ever, studies in Germany, Uganda, and Canada found no ing sex in both genders (Pedersen and Hegna 2003; Reid such association (Betzer et al. 2015; Choudhry et al. 2014; and Piquero 2014). For example, in a Norwegian study of Lavoie et al. 2010). Problematic alcohol use was also associ- youth aged 14–17 years, exposure to alcohol at home was ated with buying sex among boys in South Africa (Dunkle twice as high in boys and girls who sold sex compared to et al. 2007) and Uganda (Choudhry et al. 2014). No relation- the rest of the sample (Pedersen and Hegna 2003). Research ship was found between buying sex and alcohol problems has not examined the link between alcohol abuse at home among Ugandan girls (Choudhry et al. 2014). and buying sex. While there is some evidence for an association between Studies in Sub-Saharan Africa, Sweden, and Norway substance use and selling sex, there is disagreement about found that growing up with a single parent or non-parental the directionality. Substance use could be a consequence caretakers increased youth’s likelihood to sell sex (Choudhry of involvement in transactional sex, as substances may et al. 2014; Fredlund et al. 2013; Pedersen and Hegna 2003). numb the feelings of guilt and shame that were reported to In Sweden, 48% of students who sold sex lived with both accompany transactional sex in a Dutch study, particularly parents as compared to 61% of those who did not sell sex among girls (Walle et al. 2012). However, transactional sex (Svedin and Priebe 2007). In Hong Kong, students with could also be a means to finance addictions or a manifesta- remarried parents reported significantly higher frequen- tion of psychosocial difficulties. The association between cies of transactional sex compared to those whose parents buying sex and substance abuse has not been systematically remained in their first marriage (Lee and Shek 2013). Also, researched. being abandoned by both parents or living in orphan care has been linked to selling sex (Okigbo et al. 2014; Svedin and Sexual and Mental Health Priebe 2007; Moore et al. 2007). The association between buying sex and family break-up has not been systematically Studies have consistently found statistically significant rela- researched. tions between sexually transmitted diseases and selling sex Findings on the influence of parenting style and family among both boys and girls (Betzer et al. 2015; Jewkes et al. functioning on selling sex have been more mixed. Some 2012a, b; Atwood et al. 2011; Edward et al. 2006a, b). This studies have found a significant relation. For example, Fred- may be due to the higher number of sexual partners among lund et al. (2013) found that Swedish boys and girls who youth involved in transactional sex that was documented in sold sex reported overly strict parenting, poorer parental various studies (e.g., Betzer et al. 2015 for Germany; Svedin care, and more difficulties sharing problems with family and Priebe 2007 for Sweden; Pedersen and Hegna 2003 for members and friends. Higher levels of family functioning, Norway; Edwards et al. 2006b for the USA; Atwood et al. in turn, may be a protective factor (Lee and Shek 2013). In 2012 for Liberia; Dunkle et al. 2007 for South Africa; and; contrast to these findings, some studies found no significant Moore et al. 2007 for Uganda). A study by Norris et al. difference in family functioning between youth who sold (2009) suggests a possible link with substance abuse: Youth sex compared to youth who did not sell sex (Lee et al. 2016; who traded sex and abused alcohol had a significantly higher Moore et al. 2007; Pedersen and Hegna 2003). Parenting 1 3 Adolescent Research Review (2019) 4:115–134 129 style and family functioning have not been studied for ado- Uganda. Some studies have reported contrasting findings: lescent buyers of sex. young Liberian women who did not have a regular income in the past month were twice as likely to have sold sex com- History of Violence in Childhood pared to those who earned money (Okigbo et al. 2014). In contrast, in South Africa, higher socioeconomic status was One of the most widely examined correlates for transac- related to selling sex (Dunkle et al. 2007). Regarding the tional sex is being a victim of violence or abuse in child- buying of sex, two South African studies have reported a hood. Experiences of forced sexual activity in childhood relation with higher socioeconomic status (Jewkes et al. have been related to buying and selling sex in both genders 2012b; Dunkle et al. 2007). (Lavoie et al. 2010; Edwards et al. 2006b; Svedin and Priebe 2007; Okigbo et al. 2014; Choudhry et al. 2014; Dunkle Education et al. 2007). According to Edwards et al. (2006b), 17% of American girls and 10% of boys who had ever been forced The majority of studies has found no significant relation into sexual activity sold sex, compared to 8% of girls and between girls’ educational status and selling sex (e.g., 2% of boys without such experiences. In a Swedish study, Choudhry et al. 2014 for Uganda; Fredlund et al. 2013 for the majority (62%) of boys and girls who sold sex reported Sweden). In Uganda, Malawi, and Ghana the completion of that they had experienced sexual abuse before they started at least 6 years of schooling was not significantly associated selling sex (Svedin and Priebe 2007). Being a victim of with selling sex among girls, but it was linked to a lower physical violence more generally has also been correlated likelihood of sex work in Burkina Faso (Moore et al. 2007). with selling sex (Pedersen and Hegna 2003). Girls may be Similarly, Chatterji et al. (2005) found that in 12 countries more vulnerable than boys: two studies found a strong cor- in Sub-Saharan Africa, being in school was not predictive relation between selling sex and severe victimization in girls of selling sex in girls. A Swedish study found that male stu- but not boys (Choudhry et al. 2014; Pedersen and Hegna dents who were enrolled in a practical or vocational program 2003). A Canadian study found no statistically significant rather than general schooling were significantly more likely link between buying sex and previous sexual victimization to have sold sex (Svedin and Priebe 2007), while another (Lavoie et al. 2010). Swedish study did not find an association between the edu- Perpetration was also linked to receiving money or gifts cational status of youth and selling sex (Fredlund et al. in exchange for sex in both genders, but the experience of 2013). In Norway, male students who had sold sex had simi- sexually abusive behavior was more prevalent among boys lar grades, but less knowledge of societal issues than male (Lavoie et al. 2010; Dunkle et al. 2007; Svedin and Priebe students who had not sold sex (Pedersen and Hegna 2003). 2007). Among youth who sold sex in Sweden, 43% answered Among young men, findings on the relation between soci- that they had sexually abused another individual compared oeconomic status and buying sex have been more mixed. to 7% of youth who had not sold sex (Svedin and Priebe In-school status seemed to mitigate the risk of transactional 2007). Being a perpetrator of gender-based violence also sex in the Central African Republic and Togo, facilitate it strongly predicted buying sexual favors among males in in Nigeria, and have no significant effect in the other eight South Africa (Dunkle et al. 2007). African countries studied (Chatterji et al. 2005). A South African study found that young men with at least 10 years Socioeconomic Status of education were less likely to buy sex than those with fewer years of schooling (Dunkle et al. 2007). Findings Several studies have examined the link between socioeco- from Uganda and Sweden, on the other hand, found that nomic background and selling sex. Overall, findings suggest youth’s educational status was not associated with buying no relation between the two. For example, the study by Fred- sex (Choudhry et al. 2014; Fredlund et al. 2013). lund et al. (2013) found no differences in parents’ socioeco- nomic situation between Swedish high-school students who sold sex and those who did not. Similar findings have been Discussion reported in other Scandinavian studies (Svedin and Priebe 2007; Pedersen and Hegna 2003). In addition, research Transactional sex has received an increasing amount of among youth in secondary school in China showed that the research attention in recent years as the topic of discussions youth’s financial situation was not associated with trans- regarding developmental understanding of adolescence, actional sex (Lee et al. 2016). In Sub-Saharan Africa, the agency, empowerment, and exploitation (e.g., Fredlund et al. results have been similar: Moore et al. (2007) reported that 2013; Stoebenau et al. 2016; Wamoyi et al. 2011). Studies there were no significant associations between household have shown that transactional sex is linked to various nega- wealth and selling sex in Burkina Faso, Ghana, Malawi, and tive outcomes and health issues (Dunkle et al. 2007; Haley 1 3 130 Adolescent Research Review (2019) 4:115–134 et al. 2004), leading to the query to what extent transactional in all countries, the results were more mixed for countries in sex is to be seen as maladaptive. Considered a crime in some Sub-Saharan Africa, where prevalence rates varied widely jurisdictions, perspectives on transactional sex range from between countries. For example, lifetime selling rates among accounts that view it as behavior uprooting the moral order females in Sub-Saharan Africa ranged from 5 to 85% (Meek- and/or a form of sexual exploitation that is degrading for ers and Calvès 1999; Nyanzi et al. 2001). There were some- sellers to a form of sexual experimentation and empower- times considerable differences in prevalence rates between ment of youth (Béné and Merten 2008; Leclerc-Madlala studies within the same country. One potential explanation 2003). may be differences in measurement instruments. There Notwithstanding the important contributions of existing were substantial variations in item wordings, the number of studies to the evidence-base on transactional sex among items administered, and the reference period across included youth, gaps remain, which provide a roadmap for future studies. Interestingly, those studies that provided prevalence studies on transactional sex. First, one of the most impor- rates by gender suggest that selling rates were higher among tant research gaps is the lack of longitudinal studies. With males than females in high-income countries (e.g., Mossige the exception of two studies (Jewkes et al. 2016; Lee et al. 2001; Pedersen and Hegna 2003), whereas the opposite 2016), all of the studies identified were cross-sectional, pro- was true in low-income countries (e.g., Moore et al. 2007). hibiting conclusions regarding the time order between trans- Compared to studies on selling sex, much less research has actional sex and its correlates. Understanding this time order focused on prevalence rates of buying sex. Like selling sex, is crucial to identify potential pathways into transactional prevalence rates of buying sex were much higher in Sub- sex. Second, the distribution of studies is highly skewed geo- Saharan Africa compared to high-income countries (Jew- graphically, with the majority of studies having been con- kes et al. 2012b; Lavoie et al. 2010). Studies in both Sub- ducted in Sub-Saharan Africa and, to a lesser extent, West- Saharan Africa and high-income countries reported higher ern Europe and North America. The search found few or no buying rates among male than female youth. studies in other regions, such as Asia, Oceania, and Latin Only a few studies provided information regarding the America. Studies in these parts of the world are encouraged. situations and relationships surrounding transactional sex. Third, most research has studied female sellers, whereas Those that did suggest a profile of transactional sex in which fewer studies have examined male sellers. Given that studies sellers and buyers often meet through friends, acquaintances, show that selling rates are higher among males than females and dating websites. Buyers and sellers are often of a similar in certain contexts (e.g., high-income countries), more atten- age, although about a quarter to half of the buyers is older tion for male sellers seems necessary. Fourth, as the majority than the sellers, and money was found to be the most com- of studies has examined the prevalence of selling sex, buying monly used form of compensation for sellers. The average sex has received less attention. Studies that have reported age of onset for both buyers and sellers was around 15 years on youth as buyers highlight the need for further research. (Lavoie et al. 2010; Svedin and Priebe 2007). Despite Fifth, evidence on the situations and relationships surround- regional differences in prevalence rates of transactional ing transactional sex remains scant. More studies are needed sex, many of these characteristics seem to be similar across to be able to generalize across contexts. Sixth, little is known countries. However, some differences were observed. For about macro-level policy factors that may influence the example, substances are relatively frequently exchanged for probability of transactional sex. None of the reviewed stud- sex in Sweden (Fredlund at al. 2013), but not in Sub-Saharan ies examined the association of prostitution laws, national Africa (Moore et al. 2007; Jewkes et al. 2012b), suggesting child protection programs, or other relevant policies (e.g., that the relation between substance use and transactional sex anti-discrimination laws, gender equality measures, wealth may differ across cultures. redistribution policies) with transactional sex. Overall, prior Several individual and interpersonal characteristics are studies provide fertile ground for the development of a more correlated with involvement in transactional sex. Consist- encompassing research agenda on transactional sex that ent findings across cultures include that selling sex is asso- includes a focus on both genders, selling as well as buying ciated with involvement in other sexual behaviors (e.g., activities, the longitudinal predictors of transactional sex, being more promiscuous, having an earlier sexual debut, and the later consequences. and having a higher likelihood of consuming pornographic This article provides an overview of the prevalence, con- content), substance use, infection with sexually transmit- texts, and correlates of selling and buying sex in general ted diseases, mental health problems, family break-up, population samples of youth around the world. Overall, the and a history of victimization. On the other hand, studies findings show that there are large differences in prevalence have suggested no or mixed relations of socioeconomic rates between countries. Whereas studies suggest that trans- and educational status with selling sex (e.g., Svedin and actional sex is not common among youth in high-income Priebe 2007; Lee et al. 2016). The correlates of buy- countries (e.g., de Graaf et al. 2005), with rates below 10% ing sex include consumption of pornographic content, 1 3 Adolescent Research Review (2019) 4:115–134 131 promiscuity, substance use, violence perpetration and, Conclusion to some extent, higher socioeconomic status. However, research findings on this are less robust compared to sell- Transactional sex among youth, or the casual exchange of ing sex, due to the few studies that have examined buying sexual favors for money or gifts is raising concerns among sex. public health professionals because of its links to maladap- One of the challenges in interpreting the current evi- tive outcomes. These include sexually transmitted diseases, dence-base regarding the correlates of transactional sex violence, and substance use, among others (Dunkle et al. is that it is usually unclear whether they are risk factors, 2007; Svedin and Priebe 2007). Youth are an especially vul- consequences, or mere markers of a broader behavioral nerable group, because they tend to be more prone to risky issue. For example, although a large number of studies behaviors, including sexual risk-taking behaviors, and have has shown that both sellers and buyers are more likely to not yet reached the cognitive maturation to assess the full consume substances compared to other youth, there has spectrum of potential negative long-term consequences. To been discussion on the directionality of the relation (e.g., add to the understanding of transactional sex, this review Walle et al. 2012), e.g., whether substance use should be sought to go one step beyond existing studies by summariz- viewed as a cause or a consequence of transactional sex, ing the evidence-base on the prevalence rates, characteris- or whether both are indicators for an underlying trait. The tics, and correlates of buying and selling sex among general prime reason for this is that the temporal ordering between population samples of youth around the world. Findings the factors is unclear, since most studies to date have been from 37 studies across 28 countries revealed large differ - cross-sectional. ences between country income groups in terms of preva- This study was limited in several ways. First, the lence rates, with rates being relatively low in high-income search process of this review was not documented using countries and relatively high, but varying, in low-income the item checklist on review content and process laid out countries. Furthermore, the findings revealed a fairly con- by the Preferred Reporting Items for Systematic Review sistent (though with some exceptions) set of characteristics and Meta-Analyses (PRISMA) guidelines (Moher et al. and correlates of transactional sex across high-income coun- 2009). However, the review team ensured that the search tries and low-income countries. For example, it was found process was carefully managed: The authors agreed on that transactional sex often occurs in contexts where initial eligibility criteria for studies, conducted searches in three contact between sellers and buyers is established through comprehensive databases using a selected set of keywords friends, acquaintances, and dating websites, where the sell- in various different combinations, defined a protocol for ers and buyers often already know each other, and where data extraction and processes to validate data records, and money is the most common form of compensation. The age discussed any disagreements among authors. Second, due of onset for both buyers and sellers was around 15 years. to the relatively low number of studies that reported on Furthermore, buyers and sellers were often of a similar age, the situations and relationships that surround transactional but about a quarter to half of all buyers were older than sex, this review did not make fine-grained distinctions in sellers. Correlates of selling sex included involvement in this section. For example, the review did not report how other risky sexual behaviors, substance use, infection with situations and relationships that surround transactional sex sexually transmitted diseases, mental health problems, fam- are different by gender. More studies on these aspects of ily break-up, and childhood victimization. For buying sex, transactional sex would be helpful so that such distinc- correlates included the consumption of pornographic con- tions can be made in future literature reviews. Third, the tent, promiscuity, substance use, violence perpetration, and cross-sectional nature of the majority of studies prohibits to some extent, higher socioeconomic status. Overall, prior drawing final conclusions about the time order between studies provide fertile ground for the development of a more transactional sex and its correlates. Understanding this encompassing research agenda on transactional sex that time order—through more longitudinal research—is cru- includes a focus on both genders, selling as well as buying cial to identify potential pathways into transactional sex activities, the longitudinal predictors of transactional sex, and differentiate predictors from consequences of trans- and developmental consequences for adolescents. actional sex. The cultural context may play an important Acknowledgements The authors are thankful to members of the Vio- role here, as transactional sex can have different meanings lence Research Centre at the Institute of Criminology of the University in countries. of Cambridge for their suggestions and critical insights. In particular, the authors thank Dr. Denis Ribeaud (University of Zurich), Dr. Paolo Campana (University of Cambridge) and Dr. Simone Castello (Uni- versity of Cambridge) for providing valuable input. The authors are also grateful to Dr. Florian Roessler (University of Cambridge) for his advice and support. 1 3 132 Adolescent Research Review (2019) 4:115–134 Authors’ Contributions MK conceived of the study, participated in its of HIV infection in South Africa: A propensity-score-matched design and coordination and drafted the manuscript; MA participated case-control study. 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