Providing Services to Youth Involved in Transactional Sex in Uganda: Professional Ethics in the Context of LGBTQ+ and Gender Oppression

Background: Providers working with marginalized youth involved in transactional sex (TS) encounter complex challenges navigating structural systems of oppression facing youth and addressing their own internalized biases. TS refers to “non-commercial, non-marital sexual relationships motivated by the implicit assumption that sex will be exchanged for material benefit or status” (STRIVE, 2017; Kyegombe et al., 2020). The phenomenon of TS entails the exchange of sex often in the context of dominance and submission. In this study, we explore how providers contextualize the driving factors of TS in the lives of marginalized youth and thereby navigate the delivery of services in Uganda. We consider the systems of oppression shaping realities for AGYW and LGBTQ+ youth and examine how providers account for these systems. The key questions were: What factors drive TS among AGYW and LGBTQ+ youth? What issues, risks and benefits are involved? What behavior change models are used to address TS and to what extent do these models address structural determinants of health behavior? How do providers address systems of oppression and internalized biases?

Methods: We used a purposive sampling approach to recruit participants through contacts held by one of the researchers who has worked with various NGOs and service organizations across Uganda.

Interviews were transcribed verbatim and reviewed for accuracy by both researchers. An initial coding framework was constructed after careful review of all interviews by both researchers, which evolved through mutual review and coding. We used focused coding to examine recurring patterns within the data noting divergent data, and finally, axial coding to construct linkages between the data. We engaged in thematic analysis and triangulation of the data (Padgett, 2017). Constant comparison and case analysis techniques complemented the thematic analysis of the data using NVivo software. Themes are reported within and across data by organizing data and providing rich descriptions (Braun & Clarke, 2006).

Results: Twenty-three providers participated, including 13 women and 10 men, with a mean age of 37 (range of 20-65 years old). Providers’ professional experience ranged 1-33 years, with a mean of 7.5 years in their positions, and a mean of 10 years in HIV services. Findings show that providers navigate fraught environments of oppression. Some providers use blaming frames depicting youth behaviors while others use coded services toward the youth despite regulatory restrictions, traditional culture, and contemporary effects of colonialism. Overall, providers continually seek ways to balance internalized biases and prejudices in the broad context of structural and socio-cultural oppressions.

Conclusions: The study highlights key practice, policy and research implications including the need to address oppressive structures on the health and well-being of marginalized youth, the sensitivity of providing services in such contexts, and key strategies for both addressing internalized biases among service providers and preparing them to address systems of oppression. Legislation and policies that protect these populations need to be enacted. Providers must continually seek ways to balance internalized biases and prejudices in the broad contexts of structural and socio-cultural oppression. Further research that engages the voices of the youth is clearly indicated.