Social Norms that Sustain Transactional Sex and Associations with Sexual Health Outcomes: A Mixed-methods Study in the Comarca Ngäbe-Buglé, a Rural-Indigenous Region of Panama

"By understanding who engages in TS [transactional sex], who offers TS, the normative beliefs surrounding the practice, and the sexual health outcomes associated with TS, relevant and more effective interventions could be designed."

Culture, a normative system of shared values, holds normative behaviours in place over time through socialisation of behaviours. Despite the hundreds of distinct cultural groups within Latin America and the Caribbean, there is little prior research into how social norms affect transactional sex (TS) among Indigenous adolescents in Latin America. TS includes "noncommercial, non-marital sexual relationships motivated by the implicit assumption that sex will be exchanged for material support or other benefits". This study describes TS behaviours, normative beliefs, and factors associated with TS among Indigenous adolescents (14-19 years) in the Comarca Ngäbe-Buglé (CNB), one of the economically poorest regions in Panama.

As explained here, Social Norms Theory explains how peers influence adolescents' behaviour. During adolescence, behavioural guidance shifts from caregivers to peers, especially same-sex peers. As a result, the reference group for social norms research among adolescent populations is often the peer group. Social norms can be either descriptive or injunctive: Descriptive norms are beliefs people hold about what they think others do in a situation; injunctive norms are what people think others in their reference group approve or disapprove of. Social sanctions, the anticipation of reward or punishment from the reference group, hold norms in place.

The researchers conducted a mixed-methods study in the CNB between January and November 2018, which included (i) a qualitative study, including 20 adolescents, with participant observation and semi-structured interviews that focused on descriptive norms related to TS, and (ii) a cross-sectional study among 700 public-school-going adolescents using self-administered questionnaire to report sexual behaviour and injunctive norms related to TS. Participants in the epidemiological study were also asked to submit samples for HIV, syphilis, chlamydia, and gonorrhoea testing.

Nearly one in six adolescents in CNB (almost 20% of girls and 15% of boys) reported having been offered TS; the vast majority who were offered TS accepted the offer (81% of girls, 72% of boys). These rates are much higher than reported by adolescents in urban areas of Panama (4.8% by girls and 4.3% by boys) and are comparable to reports by adolescent girls in sub-Saharan Africa. Surprisingly, the experience of TS in CNB was similar in girls and boys, whereas elsewhere, there is a gendered experience of TS by income setting.

The qualitative study revealed that people offering TS were reported to be from within and outside of the community, including older men and women, and disturbingly, teachers. Most adolescents reported they would accept a transaction for sex with older men and women if offered. Nearly all participants mentioned that it was common for boy and girl adolescents to engage in sex with older men in exchange for money, transport, a good, or a better grade. Participants described little social sanctions for participation and reported feeling individual and collective agency in the decision to engage in TS. For example, some participants indicated they felt that the sum of adolescent behaviour could encourage or discourage TS: If one accepted the transaction, the teachers would then believe that other adolescents also wanted to participate in TS.

The quantitative study found that girls (18.8%; 58/309) and boys (15.5%; 58/379) reported similar levels of having been offered TS, and of acceptance among those offered (girls 81.4% [35/43]; boys 77.8% [35/45]). There was no association between holding norms in favour of TS and reporting having engaged in TS. However, the age- and sex-adjusted analysis found an association between HIV/syphilis seropositivity and holding norms in favour of TS (adjusted odds ratio [AOR] 2.87, 95% confidence interval (CI): 1.23-6.67). Reported forced sex was also associated with TS offer (25.7% among those who were offered TS versus 9.9% among those who were not, AOR 5.75, 95% CI: 2.87-11.52)

No household-level economic variables were associated with TS acceptance in the quantitative analysis. However, the qualitative study revealed that an individual's economic need did influence the decision to engage in TS.

Implications for policy and practice:

1. Due to widespread acceptance and feelings of agency, interventions would not be effective if they focused on eliminating the transactional component of sexual encounters. Instead, interventions should focus on economic and structural factors such as increasing economic empowerment and extreme poverty through improved cash transfer programmes, scholarship incentive programmes, or increased employment opportunities for youth.
2. To tackle HIV and syphilis prevalence, there is a need to reinvigorate condom promotion campaigns that focus on increasing access to condoms and at the same time empower young people to use them in all sexual encounters, particularly during TS. These components could be included in school-based, community based, and online sexuality education programmes.
3. Considering the association between declining a TS offer and the experience of forced sex, a comprehensive intervention could include sexuality education in schools and people-centred, community-guided projects, with clear, confidential, and protective support services for survivors of sexual violence and their families, as well greater legal accountability of violence perpetrators.