About a fifth of young sexual minority males and transgender females are estimated to be engaging in transactional, or survival sex, according to results of a new survey study by Johns Hopkins Medicine researchers. The findings, which define the practice as trading sex for money, housing and other necessities (e.g., food, clothing), were published in the February 2022 issue of the Journal of Adolescent Health and first appeared online Jan. 16. The findings affirm that transactional sex may place young Black and Latinx gay or bisexual males and transgender females at risk for exposure to HIV.

“Previous studies have focused on transactional sex among young gay or bisexual males and transgender females, but few have tried to understand the prevalence among Black and Latinx youth in these groups,” says Johns Hopkins Children’s Center adolescent medicine specialist Renata Sanders, M.D., M.P.H., Sc.M. She is the study’s first author and an associate professor of pediatrics at the Johns Hopkins University School of Medicine.

From August 2017 and January 2021, researchers surveyed 454 teenagers and young adults who are Black or Latinx. All of the subjects were between the ages of 15 and 24 and lived in Baltimore, Philadelphia, Washington, D.C., or St. Petersburg/Tampa, Florida — urban locations that have high rates of HIV and unstable housing among youth. Participants were recruited through peers, advertisements on webpages and in social media, and flyers at clinical sites serving lesbian, gay, bisexual and transgender youth, community-based organizations and events. The study included a 45-minute base line web-based survey and HIV testing. The average age of participants was 21, and about 15% of participants identified as transgender.

In addition to questions about their gender identity, experiences of sexual violence, substance abuse and financial well-being, participants were asked, “Have you ever had sex with a male in exchange for money, a place to stay or food?”

Some 22% (slightly more than one in five respondents overall) reported engaging in transactional (survival) sex. Among survey participants with HIV, 32% reported survival sex experiences. The researchers say a positive response to the question about transactional sex was associated with transgender identity, unstable housing in the previous 12 months, poorer perceived financial well-being, coerced sex and marijuana use. Youth and young adults who had a job were less likely to be engaged in transactional sex.

“A lot of the people who identify as sexual minority men or transgender woman are vulnerable and may not be accepted in their own personal environments or families,” Sanders says. “They are often displaced, and they don’t have a place to stay, which puts them at risk for transactional or survival sex and HIV.”

In addition, the researchers found that transactional sex was associated with substance use disorder. In particular, “alcohol or marijuana use may be a way of coping with engaging in transactional sex or not having a place to live,” Sanders says. More than 25% of all participants who reported using substances engaged in transactional sex, with 31% of tobacco users, 27% of marijuana users and 26% of alcohol users reporting transactional sex. Marijuana use was associated with transactional sex among young sexual minority men, while alcohol use was associated with transactional sex among youth living with HIV.

Researchers noted some limitations in the study. For example, while there was a wide recruitment of participants, the results may not represent all sexual and gender minority youth in this age group, including youth in rural areas. Also, the survey results are based on the participants’ experiences, and in some situations, youth may underreport transactional sex, or may not view sex to survive as harmful or placing them at risk.

The researchers plan to devote future studies to building and testing interventions that address economic, housing and social vulnerabilities that predispose sexual and gender minority youth and young adults to transactional sex.

For now, Sanders says health care providers, parents and others involved with sexual and gender minority youth should screen them for vulnerabilities and other health inequities, and link them to information about preventing sexually transmitted infections including HIV. Health care providers can encourage the use of condoms and pre-exposure prophylaxis medication, which can prevent HIV transmission. Parents should also talk with their adolescents and create a safe environment that accepts them, even if they don’t agree with or understand aspects of their sexual or gender identity. The goal, Sanders says, is to help those at risk understand that they are not alone, and that resources to help them are available from health professionals, community organizations and elsewhere.

The research was supported by the National Institutes of Health (R01DA043089), through the National Institute on Drug Abuse and the Johns Hopkins University Center for AIDS Research (P30AI094189).

Other scientists who contributed to the work are Aubrey Alvarenga from the Johns Hopkins University School of Medicine; Noya Galai, Ph.D., Andrea Wirtz, Ph.D., M.H.S., Chris Beyrer, M.D., M.P.H., David Celentano, Sc.D., and Joyell Arscott, Ph.D., from the Johns Hopkins Bloomberg School of Public Health; Rashida Carr from Children’s National Hospital; Alexander Lopez from Children’s Hospital of Philadelphia and Rebecca Nessen, M.P.H., from Metro Inclusive Health.