Archives of Sexual Behavior

, Volume 45, Issue 4, pp 923–933 | Cite as

“Nothing Is Free”: A Qualitative Study of Sex Trading Among Methamphetamine Users in Cape Town, South Africa

  • Melissa H. Watt
  • Stephen M. Kimani
  • Donald Skinner
  • Christina S. Meade
Original Paper


South Africa is facing an established epidemic of methamphetamine, known locally as “tik.” Globally, methamphetamine has been linked to high rates of sexual risk behaviors, including sex trading. The goal of this study was to qualitatively examine the experiences of sex trading among methamphetamine users in Cape Town, South Africa. Individual in-depth interviews were conducted with 30 active methamphetamine users (17 men and 13 women) recruited from the community. Interviews were conducted in local languages using a semi-structured guide that included questions on sex trading experiences and perceptions of sex trading among methamphetamine users. Interviews were audio-recorded, transcribed, and analyzed using analytic memos and coding with constant comparison techniques. The data revealed that in a setting of high levels of addiction and poverty, sex was an important commodity for acquiring methamphetamine. Women were more likely to use sex to acquire methamphetamine, but men reported opportunistic cases of trading sex for methamphetamine. Four models of sex trading emerged: negotiated exchange, implicit exchange, relationships based on resources, and facilitating sex exchange for others. The expectation of sex trading created a context in which sexual violence against female methamphetamine users was common. Multiple sexual partners and inconsistent condom use in acts of sex trading put methamphetamine users at high risk of HIV. Interventions in this setting should address addiction, which is the primary driver of sex trading among methamphetamine users. Harm reduction interventions may include education about HIV and other sexually transmitted infections, availability of condoms and HIV testing, and sexual violence prevention.


South Africa Methamphetamine Transactional sex Sex trading Sex work Gender 



This study was funded by Grants R03-DA033282 and K23-DA028660 from the National Institute on Drug Abuse and was supported by the Duke Center for AIDS Research (P30- AI064518). We wish to acknowledge the support of Jennifer Karp and Katie Guidera who assisted with data analysis. We are grateful to all of the men and women who participated in this study and our study staff in South Africa (Albert Africa, Tembie Mafikizolo, and Mariana Bolumbe).


  1. Adepoju, A. (2005). Review of research and data on human trafficking in sub-Saharan Africa. International Migration, 43, 75–98. doi: 10.1111/j.0020-7985.2005.00313.x.CrossRefGoogle Scholar
  2. Astemborski, J., Vlahov, D., Warren, D., Solomon, L., & Nelson, K. E. (1994). The trading of sex for drugs or money and HIV seropositivity among female intravenous drug users. American Journal of Public Health, 84, 382–387. doi: 10.2105/AJPH.84.3.382.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Barr, A. M., Panenka, W. J., MacEwan, G. W., Thornton, A. E., Lang, D. J., Honer, W. G., & Lecomte, T. (2006). The need for speed: An update on methamphetamine addiction. Journal of Psychiatry and Neuroscience, 31, 301–313.Google Scholar
  4. Birks, M., Chapman, Y., & Francis, K. (2008). Memoing in qualitative research probing data and processes. Journal of Research in Nursing, 13, 68–75. doi: 10.1177/1744987107081254.CrossRefGoogle Scholar
  5. Campbell, A. N., Tross, S., Dworkin, S. L., Hu, M. C., Manuel, J., Pavlicova, M., … Nunes, E. V. (2009). Relationship power and sexual risk among women in community-based substance abuse treatment. Journal of Urban Health, 86, 951–964. doi: 10.1007/s11524-009-9405-0.CrossRefPubMedPubMedCentralGoogle Scholar
  6. Campbell, A. N., Tross, S., Hu, M. C., Pavlicova, M., & Nunes, E. V. (2012). Predictors of relationship power among drug-involved women. AIDS and Behavior, 16, 1532–1541. doi: 10.1007/s10461-012-0208-z.CrossRefPubMedPubMedCentralGoogle Scholar
  7. Chatterji, M., Murray, N., London, D., & Anglewicz, P. (2005). The factors influencing transactional sex among young men and women in 12 sub-Saharan African countries. Biodemography and Social Biology, 52, 56–72. doi: 10.1080/19485565.2002.9989099.CrossRefGoogle Scholar
  8. Couture, M. C., Evans, J. L., Sothy, N. S., Stein, E. S., Sichan, K., Maher, L., … Page, K. (2012). Correlates of amphetamine-type stimulant use and associations with HIV-related risks among young women engaged in sex work in Phnom Penh, Cambodia. Drug and Alcohol Dependence, 120, 119–126. doi: 10.1016/j.drugalcdep.2011.07.005.CrossRefPubMedPubMedCentralGoogle Scholar
  9. Couture, M. C., Sansothy, N., Sapphon, V., Phal, S., Sichan, K., Stein, E., … Page, K. (2011). Young women engaged in sex work in Phnom Penh, Cambodia, have high incidence of HIV and sexually transmitted infections, and amphetamine-type stimulant use: New challenges to HIV prevention and risk. Sexually Transmitted Diseases, 38, 33–39. doi: 10.1097/OLQ.0b013e3182000e47.
  10. Dada, S., Pluddemann, A., Parry, C., Bhana, A., Vawda, M., Perreira, T., … Weimann, R. (2012). Monitoring alcohol & drug abuse trends in South Africa. SACENDU Research Brief, 15, 1–15. Retrieved from: Accessed 12 Feb 2014.
  11. Darke, S., Kaye, S., McKetin, R., & Duflou, J. (2008). Major physical and psychological harms of methamphetamine use. Drug and Alcohol Review, 27, 253–262. doi: 10.1080/09595230801923702.CrossRefPubMedGoogle Scholar
  12. Dunkle, K. L., Jewkes, R. K., Brown, H. C., Gray, G. E., McIntryre, J. A., & Harlow, S. D. (2004). Transactional sex among women in Soweto, South Africa: Prevalence, risk factors and association with HIV infection. Social Science and Medicine, 59, 1581–1592. doi: 10.1016/j.socscimed.2004.02.003.CrossRefPubMedGoogle Scholar
  13. Dunkle, K. L., Jewkes, R., Nduna, M., Jama, N., Levin, J., Sikweyiya, Y., … Koss M. P. (2007). Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: Prevalence, predictors, and associations with gender-based violence. Social Science and Medicine, 65, 1235–1248. doi: 10.1016/j.socscimed.2007.04.029.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Gibbs, A., Sikweyiya, Y., & Jewkes, R. (2014). ‘Men value their dignity’: Securing respect and identity construction in urban informal settlements in South Africa. Global Health Action, 7, 23676. doi: 10.3402/gha.v7.23676.CrossRefPubMedGoogle Scholar
  15. Glaser, B. G. (1965). The constant comparative method of qualitative analysis. Social Problems, 12, 436–445. doi: 10.2307/798843.
  16. Golder, S., & Logan, T. K. (2007). Correlates and predictors of women’s sex trading over time among a sample of out-of-treatment drugs abusers. AIDS and Behavior, 11, 628–640. doi: 10.1007/s10461-006-9158-7.CrossRefPubMedGoogle Scholar
  17. Halkitis, P. N., Green, K. A., & Mourgues, P. (2005). Longitudinal investigation of methamphetamine use among gay and bisexual men in New York City: Findings from Project BUMPS. Journal of Urban Health, 82, i18–i25. doi: 10.1093/jurban/jti020.CrossRefPubMedPubMedCentralGoogle Scholar
  18. Hyland, K., & Paltridge, B. (2011). Continuum companion to discourse analysis. London: Continuum.Google Scholar
  19. Inciardi, J. A. (1995). Crack, crack house sex, and HIV risk. Archives of Sexual Behavior, 24, 249–269. doi: 10.1007/BF01541599.CrossRefPubMedGoogle Scholar
  20. Jewkes, R., & Abrahams, N. (2002). The epidemiology of rape and sexual coercion in South Africa: An overview. Social Science and Medicine, 55, 1231–1244. doi: 10.1016/S0277-9536(01)00242-8.CrossRefPubMedGoogle Scholar
  21. Jewkes, R., Morrell, R., Sikweyiya, Y., Dunkle, K., & Penn-Kekana, L. (2012a). Men, prostitution and the provider role: Understanding the intersections of economic exchange, sex, crime and violence in South Africa. PLoS One, 7, e40821. doi: 10.1371/journal.pone.0040821.CrossRefPubMedPubMedCentralGoogle Scholar
  22. Jewkes, R., Morrell, R., Sikweyiya, Y., Dunkle, K., & Penn-Kekana, L. (2012b). Transactional relationships and sex with a woman in prostitution: Prevalence and patterns in a representative sample of South African men. BMC Public Health, 12, 325. doi: 10.1186/1471-2458-12-325.CrossRefPubMedPubMedCentralGoogle Scholar
  23. Jewkes, R., Vundule, C., Maforah, F., & Jordaan, E. (2001). Relationship dynamics and teenage pregnancy in South Africa. Social Science and Medicine, 52, 733–744. doi: 10.1016/S0277-9536(00)00177-5.CrossRefPubMedGoogle Scholar
  24. Kang, D., Liao, M., Jiang, Z., Zhang, X., Mao, W., Zhang, N., … Jia, Y. (2011). Commercial sex venues, syphilis and methamphetamine use among female sex workers. AIDS Care, 23, 26–36. doi: 10.1080/09540121.2011.560930.
  25. Kimani, S. M., Watt, M. H., Merli, M. G., Skinner, D., Myers, B., Pieterse, D., … Meade, C. S. (2014). Respondent driven sampling is an effective method for engaging methamphetamine users in HIV prevention research in South Africa. Drug and Alcohol Dependence, 143, 134–140. doi:  10.1016/j.drugalcdep.2014.07.018.
  26. Latkin, C. A., Davey-Rothwell, M. A., Knowlton, A. R., Alexander, K. A., Williams, C. T., & Boodram, B. (2013). Social network approaches to recruitment, HIV prevention, medical care, and medication adherence. Journal of Acquired Immune Deficiency Syndromes, 63, S54–S58. doi: 10.1097/QAI.0b013e3182928e2a.CrossRefPubMedPubMedCentralGoogle Scholar
  27. Luke, N. (2003). Age and economic asymmetries in the sexual relationships of adolescent girls in sub-Saharan Africa. Studies of Family Planning, 34, 67–86.Google Scholar
  28. Mack, N., Woodsong, C., MacQueen, K., Guest, G., & Namey, E. (2005). Qualitative research methods: A data collector’s field guide. Research Triangle Park, NC: Family Health International.Google Scholar
  29. Maher, L., Phlong, P., Mooney-Somers, J., Keo, S., Stein, E., Couture, M. C., … Page, K. (2011). Amphetamine-type stimulant use and HIV/STI risk behaviour among young female sex workers in Phnom Penh, Cambodia. International Journal of Drug Policy, 22, 203–209. doi: 10.1016/j.drugpo.2011.01.003.CrossRefPubMedPubMedCentralGoogle Scholar
  30. Maman, S., Campbell, J., Sweat, M. D., & Gielen, A. C. (2000). The intersections of HIV and violence: Directions for future research and interventions. Social Science and Medicine, 50, 459–478. doi: 10.1016/S0277-9536(99)00270-1.CrossRefPubMedGoogle Scholar
  31. Matasha, E., Ntembelea, T., Mayaud, P., Saidi, W., Todd, J., Mujaya, B., … Tendo-Wambua, L. (1998). Sexual and reproductive health among primary and secondary school pupils in Mwanza, Tanzania: Need for intervention. AIDS Care, 10, 571–582. doi: 10.1080/09540129848433.CrossRefPubMedGoogle Scholar
  32. Meade, C. S., Towe, S. L., Watt, M. H., Hobkirk, A. L., Skinner, D., Myers, B., … Pieterse, D. (2014). HIV testing behaviors and attitudes among community recruited methamphetamine users in a South African township. AIDS and Behavior. doi: 10.1007/s10461-014-0795-y.
  33. Meade, C. S., Watt, M. H., Sikkema, K. J., Deng, L. X., Ranby, K. W., Skinner, D., … Kalichmann, S. C. (2012). Methamphetamine use is associated with childhood sexual abuse and HIV sexual risk behaviors among patrons of alcohol-serving venues in Cape Town, South Africa. Drug and Alcohol Dependence, 126, 232–239. doi: 10.1016/j.drugalcdep.2012.05.024.
  34. Meekers, D., & Calves, A. E. (1997). ‘Main’ girlfriends, girlfriends, marriage, and money: The social context of HIV risk behaviour in sub-Saharan Africa. Health Transition Review, 7, 361–375. Retrieved from: Accessed 2 July 2014.
  35. Miller, C. L., Kerr, T., Frankish, J. C., Spittal, P. M., Li, K., Schechter, M. T., … Wood, E. (2006). Binge drug use independently predicts HIV seroconversion among injection drug users: Implications for public health strategies. Substance Use and Misuse, 41, 199–210. doi: 10.1080/10826080500391795.CrossRefPubMedGoogle Scholar
  36. Mojola, S. A. (2014). Love, money, and HIV: Becoming a modern African woman in the age of AIDS. Oakland: University of California Press.Google Scholar
  37. Morse, J. M. (1991). Strategies for sampling. In J. M. Morse (Ed.), Qualitative nursing research: A contemporary dialogue (pp. 127–145). Newbury Park, CA: Sage Publications.CrossRefGoogle Scholar
  38. Nakamura, N., Mausbach, B. T., Ulibarri, M. D., Semple, S. J., & Patterson, T. L. (2011). Methamphetamine use, attitudes about condoms, and sexual risk behavior among HIV-positive men who have sex with men. Archives of Sexual Behavior, 40, 267–272. doi: 10.1007/s10508-009-9566-7.CrossRefPubMedPubMedCentralGoogle Scholar
  39. Nakamura, N., Semple, S. J., Strathdee, S. A., & Patterson, T. L. (2011). HIV risk profiles among HIV-positive, methamphetamine-using men who have sex with both men and women. Archives of Sexual Behavior, 40, 793–801. doi: 10.1007/s10508-010-9713-1.CrossRefPubMedPubMedCentralGoogle Scholar
  40. Nyanzi, S., Pool, R., & Kinsman, J. (2001). The negotiation of sexual relationships among school pupils in South-Western Uganda. AIDS Care, 13, 83–98. doi: 10.1080/09540120020018206.CrossRefPubMedGoogle Scholar
  41. Panenka, W. J., Procyshyn, R. M., Lecomte, T., MacEwan, G. W., Flynn, S. W., Honer, W. G., … Barr, A. M. (2013). Methamphetamine use: A comprehensive review of molecular, preclinical and clinical findings. Drug and Alcohol Dependence, 129, 167–179. doi: 10.1016/j.drugalcdep.2012.11.016.CrossRefPubMedGoogle Scholar
  42. Parry, C. D., Pluddemann, A., Myers, B., Wechsberg, W. M., & Flisher, A. J. (2011). Methamphetamine use and sexual risk behaviour in Cape Town, South Africa: A review of data from 8 studies conducted between 2004 and 2007. African Journal of Psychiatry, 14, 372–376. doi: 10.4314/ajpsy.v14i5.4.CrossRefPubMedGoogle Scholar
  43. Peltzer, K., Ramlagan, S., Johnson, B. D., & Phaswana-Mafuya, N. (2010). Illicit drug use and treatment in South Africa: A review. Substance Use and Misuse, 45, 2221–2243. doi: 10.3109/10826084.2010.481594.CrossRefPubMedPubMedCentralGoogle Scholar
  44. Pitpitan, E. V., Kalichman, S. C., Eaton, L. A., Watt, M. H., Sikkema, K. J., Skinner, D., … Cain, D. (2014). Men (and women) as “sellers” of sex in alcohol-serving venues in Cape Town, South Africa. Prevention Science, 15, 296–308. doi: 10.1007/s11121-013-0381-y.
  45. Pluddemann, A., Flisher, A. J., Mathews, C., Carney, T., & Lombard, C. (2008). Adolescent methamphetamine use and sexual risk behaviour in secondary school students in Cape Town, South Africa. Drug and Alcohol Review, 27, 687–692. doi: 10.1080/09595230802245253.CrossRefPubMedGoogle Scholar
  46. Rawstorne, P., Digiusto, E., Worth, H., & Zablotska, I. (2007). Associations between crystal methamphetamine use and potentially unsafe sexual activity among gay men in Australia. Archives of Sexual Behavior, 36, 646–654. doi: 10.1007/s10508-007-9206-z.CrossRefPubMedGoogle Scholar
  47. Risser, J. M., Timpson, S. C., McCurdy, S. A., Ross, M. W., & Williams, M. L. (2006). Psychological correlates of trading sex for money among African American crack cocaine smokers. American Journal of Drug and Alcohol Abuse, 32, 645–653. doi: 10.1080/00952990600919062.CrossRefPubMedGoogle Scholar
  48. Semple, S. J., Strathdee, S. A., Zians, J., & Patterson, T. L. (2010). Social and behavioral characteristics of HIV-positive MSM who trade sex for methamphetamine. American Journal of Drug and Alcohol Abuse, 36, 325–331. doi: 10.3109/00952990.2010.505273.CrossRefPubMedPubMedCentralGoogle Scholar
  49. Semple, S. J., Strathdee, S. A., Zians, J., & Patterson, T. L. (2011). Correlates of trading sex for methamphetamine in a sample of HIV-negative heterosexual methamphetamine users. Journal of Psychoactive Drugs, 43, 79–88. doi: 10.1080/02791072.2011.587390.CrossRefPubMedPubMedCentralGoogle Scholar
  50. Shannon, K., Strathdee, S., Shoveller, J., Zhang, R., Montaner, J., & Tyndall, M. (2011). Crystal methamphetamine use among female street-based sex workers: Moving beyond individual-focused interventions. Drug and Alcohol Dependence, 113, 76–81. doi: 10.1016/j.drugalcdep.2010.07.011.CrossRefPubMedPubMedCentralGoogle Scholar
  51. Simbayi, L. C., Kalichman, S. C., Cain, D., Cherry, C., Henda, N., & Cloete, A. (2006). Methamphetamine use and sexual risks for HIV infection in Cape Town, South Africa. Journal of Substance Use, 11, 291–300. doi: 10.1080/14659890600625767.CrossRefGoogle Scholar
  52. Sommers, I., Baskin, D., & Baskin-Sommers, A. (2006). Methamphetamine use among young adults: Health and social consequences. Addictive Behavior, 31, 1469–1476. doi: 10.1016/j.addbeh.2005.10.004.CrossRefGoogle Scholar
  53. South African Department of Health. (2014). The 2012 National Antenatal Sentinel HIV and Herpes Simplex Type-2 Prevalence Survey, South Africa. Pretoria: Government of South Africa.Google Scholar
  54. Squires, A. (2009). Methodological challenges in cross-language qualitative research: A research review. International Journal of Nursing Studies, 46, 277–287. doi: 10.1016/j.ijnurstu.2008.08.006.CrossRefPubMedPubMedCentralGoogle Scholar
  55. Statistics South Africa. (2012). Census 2011 Municipal Report—Western Cape. Pretoria: Statistics South Africa.Google Scholar
  56. Townsend, L., Ragnarsson, A., Mathews, C., Johnston, L. G., Ekstrom, A. M., Thorson, A., … Chopra, M. (2011). “Taking care of business”: Alcohol as currency in transactional sexual relationships among players in Cape Town, South Africa. Qualitative Health Research, 21, 41–50. doi: 10.1177/1049732310378296.CrossRefPubMedGoogle Scholar
  57. Urada, L. A., Strathdee, S. A., Morisky, D. E., Schilling, R. F., Simbulan, N. P., Estacio, L. R., … Raj, A. (2014). Sex work and its associations with alcohol and methamphetamine use among female bar and spa workers in the Philippines. Asia Pacific Journal of Public Health, 26, 138–146. doi: 10.1177/1010539512471969.CrossRefPubMedPubMedCentralGoogle Scholar
  58. Vearrier, D., Greenberg, M. I., Miller, S. N., Okaneku, J. T., & Haggerty, D. A. (2012). Methamphetamine: History, pathophysiology, adverse health effects, current trends, and hazards associated with the clandestine manufacture of methamphetamine. Disease-a-Month, 58, 38–89. doi: 10.1016/j.disamonth.2011.09.004.CrossRefPubMedGoogle Scholar
  59. Volkow, N. D., Wang, G. J., Fowler, J. S., Telang, F., Jayne, M., & Wong, C. (2007). Stimulant-induced enhanced sexual desire as a potential contributing factor in HIV transmission. American Journal of Psychiatry, 164, 157–160. doi: 10.1176/appi.ajp.164.1.157.CrossRefPubMedGoogle Scholar
  60. Watt, M. H., Aunon, F. M., Skinner, D., Sikkema, K. J., Kalichman, S. C., & Pieterse, D. (2012). “Because he has bought for her, he wants to sleep with her”: Alcohol as a currency for sexual exchange in South African drinking venues. Social Science and Medicine, 74, 1005–1012. doi: 10.1016/j.socscimed.2011.12.022.CrossRefPubMedPubMedCentralGoogle Scholar
  61. Watt, M. H., Meade, C. S., Kimani, S., MacFarlane, J. C., Choi, K. W., Skinner, D., … Sikkema, K. J. (2014). The impact of methamphetamine (“tik”) on a peri-urban community in Cape Town, South Africa. International Journal of Drug Policy, 25, 219–225. doi: 10.1016/j.drugpo.2013.10.007.
  62. Wechsberg, W. M., Jones, H. E., Zule, W. A., Myers, B. J., Browne, F. A., Kaufman, M. R., … Parry, C. D. H. (2010). Methamphetamine (tik) use and its association with condom use among out-of-school females in Cape Town, South Africa. American Journal of Drug and Alcohol Abuse, 36, 208–213.Google Scholar
  63. Wechsberg, W. M., Myers, B., Reed, E., Carney, T., Emanuel, A. N., & Browne, F. A. (2013). Substance use, gender inequity, violence and sexual risk among couples in Cape Town. Culture, Health & Sexuality, 15, 1221–1236. doi: 10.1080/13691058.2013.815366.CrossRefGoogle Scholar
  64. Windle, M. (1997). The trading of sex for money or drugs, sexually transmitted diseases (STDs), and HIV-related risk behaviors among multisubstance using alcoholic inpatients. Drug and Alcohol Dependence, 49, 33–38. doi: 10.1016/S0376-8716(97)00136-1.CrossRefPubMedGoogle Scholar
  65. Wojcicki, J. M. (2002a). Commercial sex work or ukuphanda? Sex-for-money exchange in Soweto and Hammanskraal area, South Africa. Culture, Medicine and Psychiatry, 26, 339–370. doi: 10.1525/maq.2002.16.3.267.CrossRefPubMedGoogle Scholar
  66. Wojcicki, J. M. (2002b). “She drank his money”: Survival sex and the problem of violence in taverns in Gauteng province, South Africa. Medical Anthropology Quarterly, 16, 267–293. doi: 10.1525/maq.2002.16.3.267.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Melissa H. Watt
    • 1
  • Stephen M. Kimani
    • 1
  • Donald Skinner
    • 2
  • Christina S. Meade
    • 1
    • 3
  1. 1.Duke Global Health InstituteDuke UniversityDurhamUSA
  2. 2.Faculty of Health SciencesStellenbosch UniversityTygerbergSouth Africa
  3. 3.Department of Psychiatry & Behavioral SciencesDuke University School of MedicineDurhamUSA

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