Social Ecological Factors of Sexual Subjectivity and Contraceptive Use and Access Among Young Women in the Northwest Territories, Canada

Abstract

Adolescent women in the Northwest Territories (NWT), Canada, experience many sexual health challenges that are linked to a history of colonization and intergenerational effects of trauma. This study was informed by social ecological theory and explored how young women in the NWT develop sexual subjectivity within the context of contraception use and access during this time of decolonization. A total of 41 participants (aged 13 to 17 years) attended the Fostering Open eXpression among Youth (FOXY) body-mapping intervention in six NWT communities and then completed semistructured interviews. Framework analysis identified barriers to the development of sexual subjectivity that included a culture of stigma and shame surrounding sexuality; pervasive alcohol use in communities; predatory behaviors by older men; poor quality sexual health education offered in schools; and issues with accessing health services. In addition, analysis identified the following facilitators: comprehensive sexual health education; widespread access to free condoms; and positive health support networks with female relatives, peers, and some teachers. Our findings suggest the need for multiple intervention strategies within a complex social ecological framework, including arts-based interventions that focus on developing self-esteem and self-efficacy of youth, combined with interpersonal interventions that strengthen communication skills among supportive adults, and community-level campaigns that target stigma reduction and shift cultural norms.

Sexual subjectivity refers to how individuals regard themselves as sexual beings, including self-perceptions of entitlement to sexual desire and pleasure (from the self and from others), sexual self-efficacy, and sexual self-reflection (Zimmer-Gembeck & French, 2016). Sexual subjectivity is influenced by the degree to which an individual’s sexual rights are recognized and respected by others. Sexual rights that impact the development and maintenance of sexual subjectivity include the right to decide to be sexually active or not; the right to pursue a consensual, satisfying, safe, and pleasurable sexual life; the right to sexual health education and information about sexuality; the right to decide whether or not to have children and when to have them; and the right to access high quality sexual and reproductive health care services, including contraception if it is desired (World Health Organization [WHO], 2006). When youth have a strong sense of sexual subjectivity, they are able to recognize their own sexual desires as separate from the desires and pressures of others and exercise control over their own sexual decision making and behaviors (Zimmer-Gembeck & French, 2016).

Community-level indicators of sexual health, such as rates of sexually transmitted infections (STIs) and rates of adolescent pregnancy, can also indicate community-level sexual subjectivity. Sexual health indicators for Canada’s Northwest Territories (NWT) suggest youth have poorer sexual health compared to other Canadian youth. Prevalence rates for both chlamydia (2193.9 cases per 100,000 individuals) and gonorrhea (440.2 cases per 100,000 individuals) are approximately eightfold higher in the NWT than the rest of Canada (national chlamydia rate: 298.7 cases per 100,000 individuals; national gonorrhea rate: 36.2 cases per 100,000 individuals) (Public Health Agency of Canada, 2015), and STIs are highest among young people aged 15 to 24 years (Government of the Northwest Territories, 2011). In addition, even though adolescent pregnancy rates reported by the NWT have steadily decreased since the early 1990s (Government of the Northwest Territories, 2011), in 2010 the adolescent pregnancy rate for the NWT (40.0 per 1,000 females aged 15 to 19 years) was still higher than the Canadian rate (28.2 per 1,000 female youth) (McKay, 2012).

The reasons for high rates of STIs and pregnancy among adolescents in the NWT are not fully understood; however, two pathways have been described in previous research with Indigenous populations: (1) the geographic remoteness and isolation of the Arctic influencing the availability of and access to sexual health resources and services for youth (Lys & Reading, 2012) and (2) the legacy of colonization (MacDonald & Steenbeek, 2015).

Colonization and the intergenerational effects of residential schools have invalidated, undermined, and eroded Indigenous peoples’ autonomy for generations (Gesink, Whiskeyjack, & Guimond, 2018). Colonization and assimilation made traditional spiritual and cultural practices, such as rites of passage and coming-of-age ceremonies, illegal. It was during these ceremonies that youth received sexual health and relationship teachings that developed their sexual subjectivity (Flicker et al., 2013). Furthermore, Christianization, residential schools, and racism “drastically severed the ties between Indigenous peoples and how traditionally we might have received the knowledge that would enable us to make informed choices about our sexual health and relationships … many of our communities are reluctant to go anywhere near the topic of sexual health as it is viewed as ‘dirty’ or ‘wrong’” (Yee, 2009, p. 371).

In recent years, Indigenous peoples have been releasing from the oppression of colonization using decolonizing and indigenizing methodologies (Flicker et al., 2014). Indigenous youth are becoming empowered and using their personal resiliency and leadership to reclaim traditional sexual health teachings and rites-of-passage ceremonies (Wilson et al., 2016) through youth-driven, arts-based sexual health interventions that are trauma informed and rooted in cultural practices, such as the Taking Action! human immunodeficiency virus (HIV) prevention project (Flicker et al., 2013; Monchalin et al., 2016), the Sexy Health Carnival (Monchalin, Lesperance, Flicker, & Logie, 2016), and Fostering Open eXpression among Youth (FOXY; Lys et al., 2016).

The purpose of this study was to explore, during this time of decolonization, how young women in the NWT develop their sexual subjectivity within the context of contraception use and access. The results were used to inform the FOXY intervention and can be used to inform other sexual health interventions that target Indigenous youth.

Study Design

This qualitative study was grounded in the social ecological framework and conducted using arts-based methods of data collection. Specifically, individual body maps were created as an activity during participation in the FOXY intervention (Lys et al., 2016) and provided the basis for in-depth interviews (Lys, Gesink, Strike, & Larkin, 2018) that were analyzed using framework analysis (Gale, Heath, Cameron, Rashid, & Redwood, 2013).

The FOXY Intervention

FOXY is an arts-based, trauma-informed intervention developed by the lead researcher (an Indigenous woman from the NWT) and other Northerners in 2012 for young women. FOXY workshops were delivered at schools across the NWT and used several activities focused on visual and performance arts as a means to facilitate discussion and education about sexual health. FOXY utilized a peer-education model and employed adolescent peer leaders to cofacilitate workshops with adult facilitators. Some of the sexual health topics covered through FOXY programming included contraception, HIV and other STIs, healthy relationships, negotiating safer sex, gender, communication, stigma, sexual orientation, and accessing local health services (Lys et al., 2016).

FOXY workshops used theater techniques and the visual arts method of body mapping (Lys, Logie, & Okumu, 2018), grounded in a trauma-informed approach to sexual health education (Yardley, 2017). This strengths-based approach acknowledges that experiences of trauma are unique, that trauma responses are normal reactions to abnormal events, and that a multitude of factors influence individual trauma stress responses, such as age, other past trauma, family dynamics, and support systems (Yardley, 2017). Further, this approach recognizes that individuals are not deficient because of their experiences and that there is no “correct” way to respond to trauma (Covington, 2000).

The FOXY intervention was the parent study from which this qualitative substudy was derived. This article focuses on a substudy of the body-mapping activity from the FOXY intervention and uses data from in-depth interviews that were conducted by the lead researcher with workshop participants postintervention to capture participant-generated explanations of their individual body maps in the context of sexual and mental health (Lys et al., 2018). Body mapping is a guided exercise where participants create body maps on large sheets of paper using drawing, painting, or other media to visually represent aspects of their lives, their bodies, and the world in which they live (Gastaldo, Magalhaes, Carrasco, & Davy, 2012). Drawing symbols and images via body mapping is a self-empowerment process that allows participants to tell their stories using a tool that helps facilitate intergenerational dialogue (between youth and researcher), search for meaning within aspects of their lives, and engage in a strengths-based critical examination of their unique experiences (Gastaldo et al., 2012). This research project strived for a trauma-informed environment to support youth participants, which included attention to boundaries (between researcher and participant), language that communicated the values of empowerment, and creating emotional safety for participants (Lys et al., 2018).

Theoretical Framework

Social ecological frameworks of health recognize that the individual exists within a complex holistic system and that it is naive to understand human behaviors and perceptions in isolated linear terms (Besthorn, 2013). Rather, the social ecological framework emphasizes that individual sexual health behaviors and perceptions are influenced by interrelated intrapersonal, interpersonal, community, and wider societal contexts, such as culture (Glanz & Bishop, 2010; Linnan & Grummon, 2017; McLeroy, Bibeau, Steckler, & Glanz, 1988; Sallis, Owen, & Fisher, 2008). These contexts influence sexual health decision making for an individual and can either enable or inhibit healthy sexual behaviors (Skovdal, 2013).

Body mapping was a guided activity intended to provide space for participants’ introspection regarding their body, health, and relationships using the social ecological framework. This activity encouraged participants to reflect on characteristics of themselves at the intrapersonal level, including individual knowledge, attitudes, feelings, beliefs, motivations, intentions, and skills regarding sexual health. During this activity, participants were encouraged to depict aspects of their intrapersonal self, self-identify internal resources, and focus on personal resiliency (McLeroy et al., 1988). Participants were asked to map aspects of their interpersonal relationships with others, such as their partners, family members, peers, and health care providers. Through the body-mapping process, participants reflected on contexts in their communities that enabled or hindered contraceptive access and use among young people. Participants also indirectly reflected on the broader societal context that influenced their experiences and perceptions regarding sexual health and contraception.

Study Setting

There are approximately 41,462 people living across 1.2 million square kilometers in the NWT’s 33 communities, with approximately half of the population in the capital city of Yellowknife (Statistics Canada, 2012). Indigenous peoples (Dene, Inuit, and Métis) comprise half of the NWT’s population. The remaining 44% identify as Caucasian, while 5.5% are visible minorities. Communities outside of Yellowknife tend to have higher proportions of Indigenous peoples. The NWT has a young population compared to the rest of Canada, with 33% of residents under 19 years old (Statistics Canada, 2010). There are few permanent roads connecting several of the NWT communities, so many communities are reachable only by plane, boat, or ice road (during the winter). Hospitals are located in Yellowknife, Inuvik, and Hay River, with most of the remaining communities serviced by health centers or nursing stations staffed by nurses.

Method

The FOXY intervention occurred in six communities that ranged in population from 700 to 20,000 people (Inuvik, Norman Wells, Fort Smith, Fort Providence, Yellowknife, and Hay River) across all five regions of the NWT (Beaufort Delta, Dehcho, North Slave, Sahtu, and South Slave) from October to December 2013. Purposive sampling (Creswell, 2007) was used for recruitment, where school administration and teachers invited students to attend the FOXY workshop. Individuals who chose to attend the workshop were then invited by the researcher and other FOXY facilitators to participate in the study. Workshop attendees who had completed the FOXY workshop (including a body map), who were between the ages of 13 and 18 years, and who gave their written consent and had parental consent to participate were included in the study. Of the 57 workshop attendees, 41 chose to enroll in the study. The others expressed that they either did not have the time to participate or were not interested.

The lead researcher notified all potential participants during the informed-consent process that unless there was a reportable disclosure, such as child abuse, all interview data would be anonymous (e.g., body maps and interview transcripts would be assigned an identification number) and confidential (e.g., all identifying features would be removed from body maps and interviews). Parents/guardians were sent a detailed letter describing the study and were asked to sign and return a reverse consent form if they did not want their child/ward to participate in the research project. Research ethics approval was obtained from the University of Toronto Office of Research Ethics (Protocol #29038). This research is also registered with the Aurora Research Institute in the NWT (license #15292).

Body-map storytelling is a participatory qualitative research tool. Data from individual body maps were augmented with semistructured interviews so that creators could draw out the significance of the artwork for the interviewers using their own personal accounts of their lived experiences (Gastaldo et al., 2012). During the FOXY workshop, trained facilitators read a series of guided visualizations to participants that were modified from the facilitator manuals by Solomon (2002) and Gastaldo et al. (2012). Participants spent 1.5 hours creating their individual body maps on large sheets of paper using drawing tools such as chalk and markers.

Each participant was asked to complete an in-depth, semistructured interview about her body map (Lys et al., 2018) with the lead researcher in a location of the participant’s choice within three days of the FOXY intervention. The semistructured interview guide was pilot-tested with six participants for comprehension, flow, order of questions, and utility of prompts; it was further refined prior to data collection. Each individual body map was brought out during the interview and displayed so the participant could explain her own artwork. First, participants were asked to explain their body map as they saw it and how the body maps represented who they were, so the researcher could record their personal narratives. Personal narratives helped contextualize and narrate the story conveyed in each body map, while additional questions from the semistructured interview guide provided a key or detailed description of each body map drawing that aided in cointerpretation between the researcher and participant (Gastaldo et al., 2012). Interviews were audiorecorded and ranged from 27 to 67 minutes. The researcher photographed all body maps and offered them to participants to take home, along with a list of mental and sexual health resources.

Data Analysis

All interviews were transcribed verbatim, and identifying information was removed from transcripts. Data were managed with ATLAS.ti Mac software (Version 8.3.1) (ATLAS.ti Scientific Software Development, 2018), and the framework method of qualitative content analysis (Gale et al., 2013), informed by concepts of social ecological theory, was used to analyze interview transcripts. Framework analysis was used as the preferred analytic method because it is a systematic and flexible approach to analyzing qualitative data and is appropriate for research with teams where not all team members have previous experience conducting qualitative research (Gale et al., 2013). Stages of analysis included transcription, familiarization with the data, coding, development and application of an analytical framework, charting data into the framework matrix, and data interpretation (Gale et al., 2013). The analysis was an adaptive, iterative process, and the researcher revisited stages when necessary. Results are reported using the 32-item checklist of Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong, Sainsbury, & Craig, 2007).

Results

Participants ranged in age from 13 to 18 years old (M = 14.34), and all were currently in school, attending grades 7 through 12. All but four of the 41 youth participants had lived in the NWT for most, if not all, of their lives; the remaining four participants had lived in the NWT for a minimum of two years. Nearly all participants (90%; n = 37) self-identified as Aboriginal or Indigenous (First Nations, Métis, or Inuit). Most participants lived with one (26%; n = 11) or both (44%; n = 18) of their parents, though some lived with other extended family members (17%; n = 7) or in care (12%; n = 5) with foster parents or in a group home at the time of data collection. Approximately one-third of participants identified as sexually active at the time of interviews.

Participants self-reflected on their drawings of visualizations on their individual body maps, discussing several interrelated barriers and facilitators that influenced the development of sexual subjectivity for young NWT women in the context of contraceptive use and access. Participants recognized that they had sexual rights to contraception and health care services, but they also perceived that these rights were often not respected or even acknowledged by others such as their parents, teachers, or community members. Participants also discussed their own entitlements to sexual desire or pleasure, while reflecting on cultural barriers or shame and stigma regarding youth sexuality. Participants also discussed instances where they exhibited self-efficacy to use or access contraceptives; however, significant barriers to the development of sexual subjectivity still existed for nearly all participants.

Barriers

The analysis identified barriers to the development of healthy sexual subjectivity as participants described their body maps and shared stories of their experiences accessing and using contraception. These barriers included a culture of stigma and shame surrounding sexuality; pervasive alcohol use in communities that affected sexual decision making; predatory behaviors by older men; poor quality and irregular sexual health education offered in their schools; and issues with accessing health services in small communities.

Cultural Barriers of Shame and Stigma

Participants described a culture of shame and stigma regarding contraceptive use that discouraged many from accessing contraception. Typically, youth became acutely aware of stigma and shame regarding their sexuality when they sought contraceptives. One participant described how she would not go to the health center at age 13 to get condoms because she felt the health care provider would think she was too young to be sexually active and seek contraception, which made her feel too ashamed to ask for the contraception she desired (Participant 8). Another participant spoke about a time when her friend asked her mother for birth control and the mother refused to accept that her daughter was sexually active and in need of contraception:

She brought it up and her mom is just like NO. So it can be hard to get the parents to accept that their kids can have sex one day. And it can just be awkward for some people to even bring up with their parents or awkward to go to the clinic. (Participant 35)

All participants were asked if they would ever purchase condoms in their community store, and all responded that they would not due to feelings related to stigma, including discomfort, embarrassment, shyness, awkwardness, or being nervous that others in their community would know they needed contraception and judge them. When one participant was asked why she would be nervous to buy condoms, she responded, “I don’t know. It’s bad enough that I am too scared to even buy [menstrual] pads” (Participant 1). Another participant affirmed this fear of others knowing about her sexual activities and need for contraception: “It’s like you don’t want to go buy them [condoms] at the drugstore where it’s people you know who are checking you out. I know I would be embarrassed to buy them and I just might not even go” (Participant 35).

Youth in this study stated that they did not seek sexual health care and contraception from health care providers for fear of being shamed, judged, and stigmatized by health care providers. They also described being shamed and rejected by parents for being sexually active when they turned to parents for assistance obtaining contraception.

Pervasive Alcohol Use in Communities

Alcohol use is pervasive among youth in the NWT and impacted the development of sexual subjectivity of young NWT women in the context of decision making about contraceptive use. One participant shared: “My friend is pregnant. She’s in grade seven. I said, ‘Man oh man, you better use a condom next time.’ And she was like, ‘Well, I was drunk. I couldn’t help it’” (Participant 1). Another participant shared that her friends often have sex when they are drinking alcohol: “It’s a problem because it always involves drinking. Yeah. That’s what I notice among my friends. It always involves drinking” (Participant 18). Having sex frequently involved using alcohol and rarely involved the use of condoms. As one participant described: “Usually friends tell me that when they lose their virginity or they fooled around with someone they are usually drunk, and it wasn’t their fault and stuff. A lot of people tell me that the only times they’ve had sex was when they were like drunk or high” (Participant 2).

Predatory Behaviours by Older Men

One-third of participants described being both infantilized and preyed on by older men that participants referred to as “little girl (LG) hunters.” The interviewer asked all participants who used the phrase “LG hunters” during interviews where the term originated. Participants were unsure but assured the researcher that it was a commonly used term among youth in the NWT. LG hunters invited younger women (typically via text or online messaging) to party with them, often at their residences. These parties involved alcohol and sometimes would lead to sexual activity between the younger women and the LG hunters. One participant identified LG hunters as one of the biggest sexual health issues facing young women in her community, as sexual activity was often not consensual and typically contraception was not used:

I know a lot of younger people than me that are going around with older people who are like twenty and thirty and stuff. People who are sixteen who are with twenty- and thirty-[year-olds] … . I know people who got diseases and STIs from it. And a lot of the older guys also have been accused of rape and stuff … . Everyone pretty much knows each other, and everyone pretty much just adds everyone here on Facebook. I know one girl who said he was watching porn with them, and they said they usually fool around or drink. (Participant 2)

Another participant spoke at length about LG hunters in her community and how young women who did not have the financial resources to buy alcohol were more vulnerable to meeting up with LG hunters:

A lot of young girls, they do [sexual] stuff for alcohol and money. When they do get the alcohol and money, they go see their friends and their friends are usually guys, older guys, and they drink, and they take advantage of the girls. (Participant 24)

The presence of predatory LG hunters indicates to young women that their bodies are wanted for sex and can be used by these men to obtain resources in their communities. These realities can influence development of sexual subjectivity by eroding perceptions of self-worth and self-esteem if young women believe they are not wanted for relationships beyond sexual activity.

Sexual Health Education

Participants perceived their school-delivered sexual health education to be basic, lacking detailed information about contraception, and that their teachers had challenges delivering consistent comprehensive education. Participants recalled their sexual education being focused on information regarding biology, puberty, and STIs, and providing limited information about contraceptive access and options. One participant explained: “We watched a movie last year in health. It was about sperm attaching to the egg and making babies. And then this one girl had a miscarriage, so they tried again and the sperm didn’t work. That was all we had in the class” (Participant 1). When asked what she would like to learn about in school-based sexual health education, one participant responded: “Something other than puberty, because that’s all we’ve been learning since grade four” (Participant 16). Several participants noted that they had neither been taught how to properly put on a condom nor witnessed a condom demonstration in their health classes.

More than three-quarters of participants also felt that their school-delivered education was incomplete because their teachers were uncomfortable teaching sexual education. One participant stated:

Our teacher was too embarrassed to even talk about anything. And that’s reasonable, but like get somebody else to. You can’t not tell students about it because they’re going to find out one way or another, and whether you tell them about how to be safe or not, they’re still going to try new things. (Participant 20)

Participants explained that the sexual education curriculum available through the school system may need to be reviewed to ensure it matches the educational needs of youth today, especially if youth are becoming sexually active at a younger age. Participants also stressed the important roles of teachers and their level of comfort with delivering sexual education.

Discomfort With Health Care Providers

Support from health care providers can be beneficial for the development of sexual subjectivity among youth, particularly as youth form their sexual body images, develop self-efficacy, and practice control over decision making regarding their bodies. However, the majority of participants felt their relationships with health care providers lacked comfort and trust. Many health care providers were family members or friends of the family. This created a barrier to accessing services because youth felt uncomfortable and concerned about confidentiality. One participant spoke about her experience with the school nurse, who was also her neighbor:

It was just so awkward. They’re like, “Don’t worry, I can’t tell your parents anything.” But I was like yeah, but it’s still awkward! They’re my neighbor. Especially because I’ve lived next to her since I was like seven, so like six years. So it was so weird when I saw her there [at the clinic]. (Participant 11)

Another participant also described how she felt a lack of confidentiality with health care providers in her small community: “I think a lot of the doctors and nurses gossip here at the hospital … . Even yesterday, when my brother went to the hospital, he’s seventeen and they called my mom and stuff. I don’t know. I just think that’s kind of dumb, because you could make your own decisions” (Participant 4). Yet another participant spoke about her personal challenges with accessing the school’s health center for contraception due to privacy concerns: “We have the Purple Door [sexual health centre in school], and that’s it. But I wouldn’t want to go to the Purple Door… . I wouldn’t really feel comfortable discussing my personal issues with anyone at our school, really” (Participant 11).

Facilitators

Factors in the development of healthy sexual subjectivity also emerged as participants described their body maps and shared stories of their experiences accessing and using contraception. These facilitators included receiving engaging comprehensive sexual health education; access to free condoms in communities; and positive health support networks with individuals such as female relatives, peers, and some teachers.

Sexual Health Education

Education about contraception provides youth with options and choice, thus empowering youth and supporting the development of sexual agency and sexual autonomy, components of sexual subjectivity. Youth identified the FOXY intervention as a source of in-depth and comprehensive sexual health education about contraception that was more accessible and interactive than the school-based sexual health education they had received previously. One participant spoke of her confidence in her sexual health knowledge after attending the FOXY intervention: “FOXY made me feel confident about sex ed. I know a decent amount of it. [Before FOXY] I didn’t know a lot about birth control and all that stuff. But when I went to FOXY, they taught me … [FOXY facilitators] used art, like body maps, and fun icebreakers to talk to us, instead of just standing in front of the class doing boring worksheets” (Participant 19). Participants discussed the engaged style of learning of the FOXY intervention that focused on educating youth about their sexual rights to contraception and provided a breadth of information to enable choice. These participants perceived that FOXY sexual health education increased their confidence and understanding of sexual health knowledge.

Access to Free Condoms

Youth identified several ways to access condoms in their community. Availability and easy access normalized condom use. When asked where to find condoms in their communities, participants were able to list several places where they were available for free, such as bathrooms at a postsecondary education institution, public health departments, hospitals, health centers, community libraries, and the back seat pocket of taxi cabs. While health centers were the most common place mentioned to get condoms, sometimes this location was a challenge due to their hours of operation. One participant stated, “They’re easy to get in our community, but if they’re not available at the time, like on the weekends, they have to wait until Monday” (Participant 29).

For one-third of participants, condoms were available in a bowl that was located in a quiet hallway in their schools, allowing them to obtain condoms discreetly. Participants also discussed how condoms were available from their school counselors and at their school health offices, such as the Health Café in Fort Smith, the Purple Door in Hay River, and the Health Haven in Yellowknife. One participant asserted: “They’re easy to get. You can just go to the counselor’s office in the Health Café … . They’re pretty cool. You go knock on her door and you ask” (Participant 30). Participants noted that the availability of condoms in multiple locations throughout communities provides young people with options for decision making about their sexual health, thus allowing youth to exercise control over their sexual decisions.

Positive Health Support Networks With Female Relatives, Peers, and Teachers

Several participants discussed their experiences accessing oral contraceptives and reaching out to others to help them navigate the health care system to arrange an appointment or provide emotional support. One participant spoke of her experience deciding to access birth control: “For me, it happened once [having unprotected sex]. And then ever since then, I’ve kind of been using protection and I’m on birth control … . It was easy for me [to ask]. I just told her [participant’s mother] I needed it, and then we went to go get it” (Participant 10). These supportive individuals, who were most often female relatives or peers, recognized the sexual rights of participants to access sexual health services and supported participant contraceptive decision making. Another participant discussed how helpful her grandmother was for obtaining birth control: “She was cool about it. She just booked me the appointment and we went, so I was just like okay” (Participant 35). Supportive relatives who acknowledged and respected the sexual health choices and decisions of participants were particularly important for validating sexual decision making, sexual autonomy, sexual agency, and thus the sexual subjectivity of youth.

Three-quarters of participants from one community also mentioned the same teacher as a friendly, approachable person for accessing condoms, and gaining judgment-free information about safer sex and sexual health generally. Participants felt that this teacher differed from other teachers because the teacher often stated their availability to provide these resources and students felt comfortable around them and felt they were trustworthy. One participant discussed this teacher at length and expressed her gratitude: “I just felt lucky to have [name of teacher] in my life teaching me all the health stuff for our body, and so I don’t go down the wrong path of having an STI or getting pregnant at a young age” (Participant 25). The participant further expressed that this teacher recognized the sexual rights of students to sexual health information.

Discussion

Young NWT women exist within a complex system of intrapersonal, interpersonal, community, and societal factors that influence the development of intrapersonal sexual subjectivity within the context of contraceptive use and access. The impacts of colonization and residential schools and the intergenerational effects of trauma have shaped societal perceptions of youth sexuality as taboo and denied young people their right to be sexual beings. Feelings of shame and stigma about sexuality coupled with a perceived general lack of intrapersonal and interpersonal accountability while using alcohol have created a climate within communities where many young women have a difficult time exerting sexual self-efficacy regarding contraception. The co-occurrence of alcohol and sexual activity in Northern communities is a complicated relationship (Gesink, Whiskeyjack, Suntjens, Mihic, & McGilvery, 2016; Government of the Northwest Territories, 2010). Many youth in the NWT who want to have sex in their stigmatized sociocultural environment use alcohol to have sex—not only because alcohol has a disinhibiting effect but also possibly because the “shame” of sexual activity can be shared with being in an altered state. The latter is suggested by the repeated statements youth make about friends explaining their sexual activity as a consequence of being drunk yet continuing to use alcohol in highly sexually charged contexts and settings. Problematic alcohol use also has an early start in many remote communities (Government of the Northwest Territories, 2010), and alcohol can have a much darker role in sexual activity when young women who are intoxicated are sexually assaulted by individuals or groups of intoxicated men (Gesink et al., 2016).

The culture of shame and stigma around youth sexual activity was described as a key factor preventing youth in the NWT from seeking sexual health support, including contraception, and, in turn, STI prevention and sexual health counseling from health care providers and parents. High youth pregnancy and STI rates provide further evidence of the consequences of this culture. The negative reactions youth may receive from adults in positions of power regarding their sexual activity and attempts to self-protect from unwanted pregnancy and STIs is disempowering and detrimental to the formation of sexual subjectivity. The relationship between youth and health care providers can change as youth age and become independent decision makers in charge of their own health. Youth may be suspicious of health care providers because they are used to health care providers talking to their parents about their health, as health care providers did when these youth were children. Thus, they may have difficulty believing this practice can change. Youth perceptions and adaptations to their own transition can be supported or thwarted depending on the quality of interaction with health care providers, thus impacting the development of personal and sexual agency. Health care providers within NWT communities have the potential to act as barriers to or facilitators of the development of sexual subjectivity among youth. However, interpersonal relationships with these health care providers are complicated by youth perceptions that these individuals may not acknowledge or respect their rights to privacy and contraceptive services. Similarly, school-based sexual health education has the potential to be culturally relevant and focused on sexual rights, though interpersonal relationships with teachers with whom these youth feel varying levels of comfort create challenges for whether young women are given the opportunity to develop sexual subjectivity through schools.

A culture of stigma and shame surrounding sexuality impacts youth sexual self-efficacy and self-esteem, as well as the decision to access sexual health resources and services (Corosky & Blystad, 2016; Hatzenbuehler, Phelan, & Link, 2013). For young women in the NWT, this culture of shame also contributes to pervasive alcohol use—and alcohol use is often used to shift blame from the individual onto alcohol for poor or lack of sexual decision making. Alcohol use was also a way to evade interpersonal relational accountability and was used by LG hunters to take advantage of young women. Alcohol and its role in increasing risk for unprotected sex is well documented among youth populations (Kiene, Barta, Tennen, & Armeli, 2009; Leston, Jessen, & Simons, 2012; Sales, Swartzendruber, & Phillips, 2016; Senior, Helmer, Chenhall, & Burbank, 2014; Shrier, Kim Harris, Sternberg, & Beardslee, 2001), as is the cultural norm of pressure on young women to engage in sexual activity, particularly if alcohol or other drugs are involved (Senior et al., 2014). However, this is the first study to document the role of alcohol in the context of LG hunters among NWT youth.

Cultural norms also contribute to the nature of interpersonal interactions between young people and their health care providers (including perceptions of confidentiality) and can influence whether youth feel comfortable accessing sexual and reproductive health services (Alli, Maharaj, & Yacoob Vawda, 2013). Youth, especially young women, have been found to exhibit mistrust of available health services due to concerns of health care providers breaching confidentiality (Corosky & Blystad, 2016) or that they may be seen by community members while accessing services (Chenhall, Davison, Fitz, Pearse, & Senior, 2013; Lys & Reading, 2012). Adult acceptance of adolescent sexuality and recognition of the sexual rights of young people make it easier for youth to recognize that they are sexual beings, plan sexual acts (including the use of contraception), and ask for help when they require it (Schalet, 2011). Further, strong connections with prosocial peers can also support positive health behaviors such as accessing contraceptive services (Viner et al., 2012). Youth in this study indicated that supportive health networks were critical for accessing contraceptive health services in the NWT.

Many youth find school-based sexual health education problematic due to a common lack of relevancy, narrow focus, and issues with delivery (Senior et al., 2014). Comprehensive sexual health education has the potential to strengthen core components of sexual subjectivity, such as self-esteem and sexual self-efficacy, and contribute to a sense of sexual autonomy that can help youth navigate their sexual interactions (Schalet, 2011). An initial pilot study indicated that the FOXY sexual health education intervention holds promise as an effective method of delivering sexual health information through peer education and increasing STI knowledge, safer-sex self-efficacy, and resiliency among participants who identified as young women (Lys et al., 2018). Interactive, culturally relevant, arts-based approaches like FOXY (Lys et al., 2016), the Taking Action! HIV prevention project (Flicker et al., 2013), and the Sexy Health Carnival (Monchalin et al., 2016) have recently grown in popularity, particularly among Indigenous youth populations. These youth-driven programs are models for other interventions as innovative, culturally relevant, trauma-informed approaches that use a positive, rights-based lens toward youth sexuality and reject the notion that youth are at-risk victims of their historical circumstances.

Limitations

This study reflected the experiences of youth who lived mostly in the capital city and regional centers in the NWT. Communities that were included in this study had populations that ranged from approximately 21,000 to 770 people. Of the NWT’s 33 communities, 23 have populations that are less than 770. Youth in smaller, more isolated NWT communities may face additional or different challenges toward developing sexual subjectivity regarding contraceptive access and use than participants in this study. Further, this study explored only the contraceptive experiences of young NWT women to the exclusion of other genders. Future research should attempt to capture the voices of youth of all genders and in smaller NWT communities to ensure representation of youth voices from across the NWT. Also, the interviewer was a cocreator of the FOXY intervention, and some participants narratives may have been influenced by a social desirability bias to discuss the FOXY intervention positively. However, the lead researcher’s active involvement throughout the intervention may also have increased rigor and validity, because being a lifelong Indigenous resident of the NWT provides valuable context when analyzing and interpreting the findings. There is also debate that this insight into the lived experience of young women in the NWT may have potentially limited analysis and interpretation of the findings precisely because the lead researcher is from the NWT and may not challenge assumptions in the same way an outside researcher would. Finally, additional research should examine the potential implications of FOXY intervention effects on participant perspectives when qualitative interviews occur postintervention, as they did in this substudy of the body mapping activity. For instance, FOXY participants may feel maximally empowered at the conclusion of the intervention, and there may be a waning effect on sexual subjectivity over time.

Implications

The complex process of intervention development often requires partnerships across a range of diverse community and government organizations, as well as the incorporation of multiple intervention strategies within a single, comprehensive social ecological framework (Stokols, Allen, & Bellingham, 1996). The development of complex social ecological interventions that address sexual subjectivity among NWT youth can be a challenge for health care providers and community organizations that are potentially understaffed or underfunded, though the problem is not insurmountable. Interventions should be carefully thought through and include the meaningful input and direction from young Northerners to help ensure relevance and potentially increase uptake by youth. The development of intrapersonal sexual subjectivity is best supported by a holistic approach to sexual health that emphasizes attainment of physical, emotional, mental, and social well-being in relation to sexuality (WHO, 2017). Thus, Logie, Lys, Okumu, and Leone (2017) highlighted the need to address substance use and mental health in sexual health interventions for NWT youth to ensure that interventions are holistic, culturally inclusive, and trauma informed (Logie et al., 2017). In addition, our results suggest that supportive adults are highly effective at normalizing and facilitating access to contraception, which further suggests that interpersonal interventions to develop and strengthen the communication skills of supportive adults (parents, guardians, and others) who interact with youth can also help support youth to build healthy sexual subjectivity.

Culturally relevant, community-focused campaigns that use a sexual rights–focused lens and aim to reduce or eliminate the stigma, shame, and embarrassment associated with accessing contraception can have an effect on cultural norms that currently act as barriers to the development of sexual subjectivity among NWT youth. Health service policies can also be updated to better support youth to develop sexual subjectivity by reflecting and supporting mature minors to access contraception and make their own health decisions without fear of judgment, breach of confidentiality, or involving their parents or guardians. Health care providers should strive for acceptance of adolescent sexuality and the recognition of the sexual rights of young people as sexual beings with needs and desires. Finally, in the context of a culture of LG hunters that can undermine the development of sexual subjectivity for young women, further research should explore how men can (and some do) support young women in their communities, and communities should develop strategies and interventions to help boys and men strengthen their supportive roles for young women.

Acknowledgments

We extend a heartfelt thank-you to all the young women who shared their experiences for this study. Many others supported the lead researcher and this project through its various stages, including Carmen Logie, Gwen Healey, Nancy MacNeill, Kayley Mackay, Julie and Kevin Lys, Hiedi Yardley, Shira Taylor, Jenn Mason, and Remi Gervais.

Additional information

Funding

The lead author received financial support in the form of bursaries from the Northern Scientific Training Program, Government of Canada (1516-HQ-000007), Indspire, and the Aurora Research Institute; a Canadian Institutes for Health Research Vanier Graduate Scholarship (CGV192429); and funding from the Public Health Agency of Canada.