The Interplay of Multiple Influences on the Development of Sexuality in Late-Adolescence—A Grounded Theory Study

Abstract

The aim of this grounded theory study was to explore late-adolescents’ process of sexual development along with their information- and support-seeking behaviors in a Swedish context. Data were collected in semi-structured interviews with late-adolescents aged between 18 and 21 years in high schools in central Sweden. The results showed that late-adolescents’ sexual development involved seeking for knowledge, discussing norms and attitudes, learning through interactions, and growing through practice and experience. Information- and support-seeking behaviors were observed throughout their developent. This study highlights that, in order to be able to provide adequate help and support, healthcare professionals need to have an awareness of the changing information and support needs of adolescents in our constantly changing and diverse society.

Keywords:

• Adolescents
• attitudes
• grounded theory
• knowledge
• sexual and reproductive health and rights
• sexual health promotion
• sexuality
• support

Introduction

Adolescence is an intense period in a life marked by the occurrence of rapid physical, psychological, intellectual, emotional, and social change. Compared to earlier generations, today’s adolescents often hold more liberal views on sexuality and show a wide variation in how they express sexuality and sexual relationships. In addition, their general knowledge of sexuality is better than previous generations (Häggström-Nordin et al., 2016). However, the transition from childhood to adolescence is a period that may lead to both psychological and physical health problems. Problems can arise in the areas of developing one’s identity, sexually transmitted infections (STIs), issues concerning sexuality, and unintended pregnancy (Meleis, 2010). Early in adolescence, adolescents start becoming more independent of their parents, developing clarity regarding their sexual identity and orientation, experimenting with relationships, and gaining sexual experience. This includes learning how to interact with a potential partner, how to negotiate, communicate and articulate desires and boundaries, and how to show respect (WHO & Federal Center for Health Education BZgA, 2010). Late adolescence is the age group in focus in this study. Brown (1999) defined late adolescence as being between the ages of 17 and 20 years. The process of forming one’s identity in the areas of love, work, and world views, which begins at adolescence, primarily takes place between the ages of 18 and 25, a period described as emerging adulthood (Arnett, 2000). According to Arnett (2015) emerging adulthood has evolved as a developmental stage due to changes in society during the past half century. For many young people education may last longer longer, frequent job changes before settling into a more permanent position, and marriage and parenthood being postponed. This allows for a freedom to explore different options, while at the same time struggling with uncertainties leads to anxiety, not knowing where their exploration will lead them (Arnett, 2015). There are five distinctive features which distinguish young adulthood from adolescence; exploring ones identity, instability in love, work and place of residence, being more self-focused, along with feeling in-between in the transition, i.e. neither identifying as an adolescent nor as an adult (Arnett, 2015). Gilmore (2019) agreed that there is value in considering emerging adulthood as a developmental stage. It offers a new view on human development as it is changing in a transformed world (Gilmore, 2019). Young people today are forming their identities in a post-structural society that is characterized by increased complexity and diminishing traditions, norms, and values, which, to a greater degree than ever before, has led to individuals being left to find their own path in life (Johansson, 2016).

A definition of sexual health was developed by WHO (2006):

Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. (WHO, 2006).

In Sweden, the general population reports having good sexual and reproductive health (The Public Health Agency in Sweden, 2019). More than half of young straight and gay men and lesbians and bisexual women aged between 16 and 29 reported that they are satisfied with their sexual life. However, more than half of young women aged between 16 and 19 reported that they had experienced sexual harassment. This was also experienced to a greater extent for gay, bisexual, and trans persons than straight and cis persons. Adolescents were at risk of sexually transmitted infections (STIs) and unintended pregnancies (The Public Health Agency in Sweden, 2019). On a global level, more than one million STIs were acquired daily. In addition, ∼12 million girls aged between 15 and 19 years gave birth each year in developing countries, and nearly 10 million girls of the same age in the developing world experienced unintended pregnancies (WHO, 2020).

Research has shown that adolescents are concerned about sexual health and need information about pregnancy and STIs (Smart et al., 2012; Unis & Sällström, 2020). Smart et al. (2012) found that adolescents have also identified romantic relationships as something that could be experienced as stressful. Several studies have been carried out investigating the needs of adolescents regarding health information regarding sexual health and relationships, and their preferences regarding where they go to find this information (Gray et al., 2005; Jones & Biddlecom, 2011; Marcell & Halpern-Felsher, 2007; Selwyn & Powell, 2007; Whitfield et al., 2013). Previous research has shown that adolescents initially prefer using informal sources for sexual health information, before seeking information from formal sources (Eckstrand et al., 2017; Gray et al., 2005; Jones & Biddlecom, 2011; Marcell & Halpern-Felsher, 2007; Selwyn & Powell, 2007; Whitfield et al., 2013). Informal sources for sexual health information include friends and mothers (Whitfield et al., 2013), partner and mothers (Selwyn & Powell, 2007), trusted peers and adults (Gray et al., 2005; Marcell & Halpern-Felsher, 2007), partner and friends (Marcell & Halpern-Felsher, 2007), and family members (Jones & Biddlecom, 2011). School-based sources were the preferred formal sources (Whitfield et al., 2013). More recently, research has focused on adolescents’ support-seeking behavior online with regard to issues related to online sexual experiences and interactions (Razi et al., 2020), and the process of seeking support online (Starling & Cheshire, 2016). Whitfield et al. (2013) found that sexual health information seeking is gendered and changes across year groups as sexual activity increases (Whitfield et al., 2013). Some of these studies are not recent, therefor new reseach can be warrented.

Adolescents reported using personal communication with adults, such as doctors, nurses, parents, and teachers to access information. The Internet was also a common source of information for this age group (Smart et al., 2012). A recent integrative review (Kim & Kim, 2021) on sexual health information-seeking behaviors among adolescents found that adolescents preferred trustworthy sources for information and compared the content of different sources to judge the quality of information. Compared to early adolescents, late adolescents preferred to seek sexual health information from peers, along with websites and social platforms on the internet (Kim & Kim, 2021). The integrative review included only seven articles published between 2010 and 2016.

Kennedy et al. (2014) identified gaps in information targeting adolescents on sexual and reproductive health rights. These gaps included pregnancy prevention, condom use, puberty, sexuality, and relationships. Adolescents in this study named peers and healthcare workers as their preferred sources of information, as they were considered knowledgeable and trustworthy. Schools were also an important source of information, albeit underutilized (Kennedy et al., 2014). Unis and Sällström (2020) found that students who experienced sexuality education in Swedish schools as good at providing factual knowledge but that it placed too much focus on the negative outcomes of risky behavior, such as STIs and unintended pregnancy, and that it was not adapted to their needs. In this study, adolescents viewed sexuality education as important for gaining life skills, such as learning how to handle situations relating to sex and relationships and for learning practical skills (Unis & Sällström, 2020).

Gaps have been identified in the sexuality education information given to late-adolescents and teachers are not always aware of the needs of late-adolescents and what they want to learn about. Due to society rapidly changing its perspective on sexuality and relationships, up-to-date research is needed that can illuminate these changes and how they affect adolescents in developing their identity and sexuality. However, due to the rapid nature of these changes, little is known about how late-adolescents get information and support during the time their sexuality and sexual identity are developing and when they start forming sexual relationships. Up-to-date information on what late-adolescents want to learn about in relation to sexuality and relationships, along with how they seek information and negotiate support-seeking could be of great value for attuning sex education and support for better promotion of sexual health. The review of the literature on sexual health information and support-seeking behaviors among adolescents has shown a need for more up-to-date studies which this paper could contribute to. The aim of this study was to explore late-adolescents’ process of sexual development along with their information- and support-seeking behaviors in a Swedish context.

Methodology

The study had a qualitative design based on grounded theory according to Charmaz (2014), who developed a constructivist grounded theory approach in which grounded theories are constructed through involvements and interactions with people, both present and past, perspectives, and research practices. Morse (2016) means that when using a symbolic interactionist view in grounded theory, changes within social groups along with the processes involved can be understood. The focus is on what is going on or what is happening (Morse, 2016). The constructivist grounded theory approach was chosen because it was appropriate for the aim of the study and to construct a theory that described the process of adolescent sexual development and focused on how adolescents view their situation, based on how and why they construct meaning and carry out actions in different situations. In constructivist grounded theory meanings are negotiated and understood through interactions with others and how these are interpreted in the current situation. Therefore, constructivist grounded theory is an appropriate approach while adolescent sexual development involves social interactions, and also in uncovering actions adolescents take when they are actively developing and constructing their sexuality. Data were collected through semi-structured interviews. According to Charmaz (2014), grounded theory can be generated from rich data which can come from diverse kinds of data depending on the topic and access, and varied data-gathering strategies can be adopted. Interviewing is commonly used in Grounded Theory, to learn more about the world while at the same time pursuing to construct theory.

Participants

The sample consisted of 21 adolescents enrolled in four high schools in three communities, aged between 18 and 21 years. Normally, students in high school in Sweden are between the ages of 16 and 18 years, but students coming as unaccompanied refugee minors are often placed in an earlier school year to catch up on their education, therefore four of the participants were over the age of 18. Participants consisted of eight students who identified as men, twelve as women, and one student who identified as non-binary. Four of the students had a non-Swedish ethnic background. To have a diverse sample, the schools selected had varied characteristics. Two were located in a small town and served rural areas, one was a small private school teaching primarily academic programmes of study located in a small city, and the third was a large high school teaching both practical and academic programmes and was also located in a small city. Including both academic and practical courses allowed for a wider variation in the socioeconomic background of participants. All the schools were located in central Sweden. Their principals were contacted and meetings were scheduled to provide information about the study and to obtain consent to conduct the study. The principals assisted in choosing the classes that the first author visited to inform students about the study and how participants would be recruited. Schools were not informed which students participated in the study. Theoretical sampling was carried out in accordance with grounded theory (Charmaz, 2014). In the initial sampling, students from selected classes at different schools were recruited. To include more men, participating boys were asked if they had a male friend who might be interested in taking part and if so, to ask him to contact the first author for more information. To recruit LGBTQ adolescents, a youth clinic and an organization for LGBTQ youth were contacted.

Verbal information about the study was given in selected classrooms and students were given the opportunity to ask questions. They were also given written information along with a consent form. No formal consent was needed from parents due to the age of the students being recruited. Students who were interested in participating were asked to notify the first author with their contact information via SMS using a smart phone. At this point, interested students got the opportunity to meet the researcher before deciding about participation. To attain a rich view of the phenomenon being studied, a sample of adolescents of different ages, backgrounds, and genders was strived for. As the study proceeded, new criteria for inclusion were introduced in accordance with the grounded theory methodology.

Procedure

Data collection was carried out by the first author via semi-structured interviews that were conducted with the students. Ten of the interviews were individual, four were with two participants who were close friends, and one was with three participants. An open approach to the use of different forms for interviews was included in the method. Because of a reluctance from students to participate in individual interviews, participants were offered the possibility to participate in pair interviews. This increased my interest in participation. Three students requested to be interviewed together. According to Charmaz (2014), varied data-gathering strategies can be adopted for collecting data (Charmaz, 2014). Dyadic interviews, referring to interviewing two participants together, have been found to offer some advantages compared to individual in-depth interviews and focus group interviews (Eisikovits & Koren, 2010; Kvalsvik & Øgaard, 2021; Morgan et al., 2013, 2016). Combining individual in-depth interviews with dyadic interviews can allow for comparisons and cross-checking as a form of triangulation (Eisikovits & Koren, 2010). In grounded theory, combining individual interviews with dyadic interviews can be useful during the analysis when identifying recurrent patterns and the saturation of concepts, which supports the emerging analytical framework (Morgan et al., 2013). Although individual interviews allow participants to share the information which may have been withheld with another participant present, dyadic interviews participants, through extended conversations, can stimulate ideas that might not have occurred to the individual, and to co-construct rich data on the research topic (Morgan et al., 2016). Compared to focus group settings, dyadic interviews were more personal, allowing for more comfort and openness and the opportunity to share experiences and reflections, which can lead to a wide variety of topics allowed to emerge and data at an in-depth level that may not be found in individual interviews (Kvalsvik & Øgaard, 2021; Morgan et al., 2013).

All participants were cautioned not to repeat anything that was said in the interview. To maintain confidentiality, participants could not be identified through the results. The open-ended questions focused on participants’ need for knowledge regarding sexuality and relationships, their need for support in questions related to sexuality, and where they would turn when in need of support in these questions. An interview guide was used and modified through theoretical sampling to be able to follow new lines of inquiry that were identified in the analysis. Additional questions were included in the interview guide relating to the connection between sexual health and mental health and lesbian, gay, bisexual, transsexual, queer, (LGBTQ), and gender norms. According to Charmaz (2014), an interview guide should be treated as a flexible tool to revise when needed (Charmaz, 2014). This was ongoing throughout the interview process and was carried out through discussions between the authors and with help from the memo-writing process.

Interviews were designed to have the characteristics of a dialogue. Initial questions asked included: Can you tell me what you think you need to know about sex and relationships? Do you feel the need to seek knowledge or support about sexuality or relationships and if so what areas do you need this in? If you were to seek support for questions about sexuality or relationships, to whom or where would you turn? The interviews were then adapted to accommodate the participants’ answers and reflections and follow-up questions were asked, such as What does that mean? Can you explain further? Can you tell me more about that? The interviews took place in appropriate private rooms at either the participants’ high school or at the university and lasted between 20 and 40 min. On one occasion, a student was contacted after the interview to clarify a point discussed in the interview and to pose further questions to the student. Interviews were carried out until data saturation was reached, which, according to Charmaz (2014), occurs when no new properties of the pattern emerge in the theoretical categories. This was considered to have been achieved after a total of fifteen interviews.

Analysis

The interviews were recorded, transcribed in verbatim, and analyzed simultaneously using grounded theory methodology according to Charmaz (2014). Charmaz (2014) states that in constructivist grounded theory, researchers must examine how their preconceptions shape the analysis and acknowledge the subjectivity and involvement of the researcher in constructing and interpreting the data. In the current study, the first author has a background as a school nurse and knowledge and experience in working with adolescents’ sexual health. Reflections on former knowledge and preconceptions were addressed through discussions with the other authors who had different backgrounds. Memo writing was also used to reflect on preconceptions in relation to the analysis, in order to ensure that the construction of the results stay grounded in the data. Reflexivity, according to Charmaz (2014), means scrutinizing your experience, decisions, and interpretations to show your participation in the research process, including interests, positions, and assumptions. These measures helped to ensure the trustworthiness of the results.

Memo writing was carried out after each interview throughout the entire analysis to develop ideas about codes and emerging theory, and to develop new questions that could be used in upcoming interviews. This was also useful in directing further data collection. In the process of analysis, new questions arose from the previously collected data which led to new questions being included in the interview guide, according to theoretical sampling. The purpose of the interviews then conducted was to verify data from earlier interviews and to deepen the understanding of prominent data. Analysis began with initial coding which was carried out line by line, staying close to the data, and codes were expressed with words reflecting action. This was followed by focused coding in which the initial codes were compared and categorized while looking for codes that are more significant and conceptual. Theoretical coding followed, looking at how codes relate to each other and increasing the abstraction of the analysis to help theorize the data. In this step, codes were translated into English. The emergent theoretical codes were then sorted and re-sorted which resulted in the construction of four categories. Clustering helped to create and organize the categories and their defining properties and relationships. Diagraming was used as a tool for theoretical development, in order to create a visual representation of the categories and their relationships. Theoretical sampling, constant comparison, and memo-writing were used simultaneously throughout data collection and the analysis process. The analysis led to the construction of a theory which is grounded in the data as described by Charmaz (2014).

Ethical considerations

The study was approved by the Regional Ethics Approval Board in Uppsala, dnr 2018/403.

Results

Four categories emerged in the collected data; Seeking for knowledge, Discussing norms and attitudes, Learning through interactions, and Growing through practice and experience. The results showed the interplay of multiple influences on the development of sexuality in late-adolescence. Adolescents’ need for knowledge and the knowledge they seek was changing as they aged and developed. Discussing norms and attitudes related to sex was necessary for them to increase their self-awareness. Interacting with others facilitated learning about sexuality and relationships. Practice and experience supported growth and development and lead to self-awareness and the mastery of sex, which allowed for fulfilling relationships. During this process of development, adolescents sometimes felt the need to seek information and support. These findings were integrated into the categories and showed how late-adolescents assessed the different sources of information and support they had available to them and how they negotiated choices in their information and support seeking.

Seeking for knowledge

The need for knowledge changed with age and development. When younger, participants had more questions about equality, relationships, factual aspects, protecting themselves, and sexual identity. With experience came a greater desire for knowledge of relationships and how to think about and handle them. Sex and relationships became more serious issues. As the experience of sex and relationships increased, the need for knowledge in other areas, such as contraceptives and how they affect you, also increased. One woman explained,

Now I think that it is more about relationships, how to relate to different relationships. Because now it feels like things have become more serious, so I think that I need some guidance, how a relationship might work, how you should think, and then a lot about contraceptives. (Interview 5, woman, age 18).

Factual knowledge and knowledge of relationships were highly valued. Participants experienced a lack of knowledge of facts related to sexuality and relationships, and wanted to know more about mutually consented sex, STIs, contraceptives, gender roles, and the consequences of sexual behavior, in order to be able to take more responsibility. Participants also wanted to learn more about how to have sex along with how the body reacts to sex, as well as more existential issues, such as desire and love. Knowledge of body image regarding normal sex organs was something lacking; that there is a wide range in the appearance of sex organs that are considered normal. Participants reported insecurity regarding whether or not their own body was normal. In general, factual knowledge was seen as a necessary base on which to form your own perspectives. It was also seen as valuable to have before engaging in sex for the first time.

Knowledge of relationships was seen as important and in many cases lacking. This included how gaining a realistic view of relationships involved realizing that they are different for everyone, that they are unique, and that some can be unhealthy. There was a lot of insecurity among participants in matters relating to relationships. They wanted more knowledge of how to initiate and build a relationship, and how to handle difficult situations, such as abuse and breaking up.

Participants wanted more sexuality education progressing all the way up to high school. They stated that it is good to begin with sexuality education early on in their schooling, which would help by opening up the topic for discussion. They experienced that sexuality education classes did not always fulfill actual needs. Topics relating to sexuality and relationships were sometimes brought up in others subjects in school, such as social science and Swedish classes. Topics that were not covered or that participants thought should be brought up more thoroughly included knowledge of LGBTQ people and their lives, sexual identities, and same sex relationships, along with how to have sex. Participants also wanted to learn about how to have a relationship. One participant commented on sexuality education:

They should talk about it in a different way, because now it’s just about anatomy and so on, and not so much about how you should act and so on. That’s the way it is, we already know (about anatomy). Some lesson you could have like that, but then you could have a little more about LGBTQ people and how to act (during sex and in relationships), and everything else, because that’s what young people are mostly interested in and need to know about. I don’t think we are really so interested in biology, even though it is perhaps good to know. (Interview 13, woman, age 18).

Participants were interested in learning about the opposite sex and how they think about sex and relationships and expressed a wish for more mixed groups with both men and women in sexuality education. Another important aspect mentioned for facilitating discussion was having a good teacher who is open and not embarrassed to talk about the subject. Participants also experienced that lectures followed a set plan that did not allow much time for discussion. They believed that discussions led to further discussions, which would lead to deepened learning.

Participants also wished to be provided with more information about youth clinic services. A few of the men participating in the study were unaccompanied refugee minors who had not received any sex education before arriving in Sweden. They had been provided with special sex education in youth clinics, which was highly valued and appreciated. One man explained,

And if he hadn’t come (from the youth clinic) to me, then I would never have sought support or talked to anyone about these things, I perhaps would have read about it, but not talked to anyone. (Interview 10, man, age 21).

Youth clinics were a well-known place for seeking support and getting professional help for several different questions relating to sexuality, physical health problems, contraception, testing for STIs, or support or counseling—the youth clinic was seen as a place where a wide range of professional help is available. One woman stated, “You go to the youth clinic for more specific matters, when you need help with something” (Interview 5, woman, age 18). Another option when questions about sex arise is the school nurse, who is seen as knowledgeable, however school nurses are not always available and sometimes adolescents forget that they are there. Boys appreciated being able to speak “man to man” with a male nurse who perhaps had a better understanding of what they were going through. Counselors were another professional group identified who could provide support. Counselors were seen to be knowledgeable about relationships and good to talk to about sensitive issues, especially if there is no one else to turn to. Counselors could also be a gateway to the youth clinic. For many seeking professional support, it was important that support was offered discreetly. One woman explained, “I think that it is good if (the counsellor’s room) is discreetly located. It is good to feel that no one knows that you went there” (Interview 2, woman, age 18). A few participants stated that they could turn to their teacher for support, in cases where they had a good relationship with their teacher.

Participants sought information about sexuality and relationships in several ways, including searching the Internet. Most participants stated that they only used reliable sources, but that they thought that others use unreliable sources. Using the Internet was often the first step taken to find facts before seeking information and support elsewhere. Accessing pornography on the Internet was seen as a way to learn about how to have sex, however, participants were ambivalent about pornography and claimed that they needed to be critical; they suspected that Internet pornography does not reflect reality, and can affect how sex is viewed, and can lead to pornography addiction, as noted in this excerpt:

Often it is from (porn films) that you learn, and perhaps you should think that it isn’t like what you see on film. Yes, it can give a really distorted view of everything. I think that we should talk more about that in school. (Interview 15, woman, age 18).

Discussing norms and attitudes

Participants found themselves in an environment marked by norms and attitudes and it was necessary for them to discuss these to become self-aware and decide how to relate to them. Heteronormality and gender roles are topics that are often mentioned. They stated that adolescents identifying as straight were becoming aware of their heteronormality, and they reflected on what it would be like to not be straight in a heteronormative society. Schools could often be seen as heteronormative environments, and adolescents believed that addressing LGBTQ people and their lives more in school would contribute to LGBTQ adolescents feeling more included. One participant explained,

Well, it is when you talk more about this, LGBTQ people and so on, which isn’t being talked about currently. It can be good for people who aren’t attracted to the opposite sex, if you can say that, then it would be good for them, so that they would feel included. (Interview 13, woman, age 18).

Participants stressed the importance of acceptance and self-acceptance and that LGBTQ celebrities could act as important role models. There were different views about how adolescents would experience coming out at school. Most believed that they would be accepted by the majority of people but not by all. Some people at school and on social media are thought to have negative attitudes. Participants spoke about girls reacting strongly toward this and reprimanding students, mainly boys, who harassed others for their sexual preference. Female participants believed that boys have more difficulty than girls in accepting being gay. Coming out was thought to be easier if you have good friends that you feel secure with. Norms relating to sexual orientation were also being discussed among the male participants with non-Swedish cultural backgrounds, as one man commented,

It is something you have, your background. There are boys who want to find boys here in Sweden. But where we come from, it is not normal for boys to chase after boys. (Interview 14, man, age 18).

Other topics relating to sexuality and sexual identity were also brought up, which friends could talk about. Gender norms were discussed and differences identified—men were often described as noisy, joking around, and not being interested in talking about important or sensitive issues, while women were described as being able to talk about anything in their womens’ groups or close friendships. Talking jokingly and not being serious could, however, be a way to deflect sensitive issues. Masculinity as a norm was something that the men related to, and they talked about showing or hiding their emotions. Some men were actively changing these norms and becoming open to talking about these topics. One man remarked,

Personally, I have no problem with (talking about problems), I think that it lies in that we happen to be men. It’s more about how we were brought up, we shouldn’t talk that way. So, if you change that then I believe things will look completely different. I don’t believe that it lies in us, like in our genes, that we don’t have any problems. (Interview 7, man, age 19).

Participants also remarked that boys are not one homogenous group, and that they can differ when it comes to norms and attitudes. One man went on to explain by giving an example:

There was a gay couple in our school and they were accepted by the vast majority. Then there were a few guys who sat there and talked negatively about them. So, it differs widely but I still believe that at our school, most are accepted, but there are, of course exceptions, the cool guy who has difficulties with it, the faggot thing can get very heated. (Interview 7, boy, man 19).

Participants were also concerned with attitudes about sex, which differed regarding whether or not girls should have many sex partners. They claimed that a common experience for girls was dealing with rumors about them having had sex, which was experienced as unpleasant to go through. They were aware of how easy it is to speculate and spread rumors. They spoke about some adolescents engaging in sex despite not wanting to. Reasons for this they discussed could be being in love with the other person, how they were as a person, and maturity.

Other topics participants discussed included having sex while under the influence of alcohol. Combining alcohol and sex could result in adolescents taking risks, such as having unprotected sex or having sex with someone they would regret later. They stated that it is often after having sex that they thought about the consequences and how it would have been better not to have had sex when drunk. They reported discussing these topics with their friends, and they also considered these to be important topics to be included in sexuality education.

Gender played a role in support seeking among the study participants. Womens’ friend groups were a strong source of support and could offer acknowledgment. At the same time, there were also examples of mixed-gender friend groups where it was possible to talk about sex and relationships. It was most common for participants to talk with a friend of the same sex, but there were exceptions. Some of the men participating in the study found it easier to talk with a woman, as women are considered to be more accepting and used to talking about emotions. Some of the men preferred having a close friend to talk to and believed that there are boundaries that men are afraid of crossing when talking about their problems. One man stated, “I won’t talk to just anyone, I’ll only talk with my closest friends. There are limits to what you can talk about with your other friends” (Interview 6, man, age 20).

Learning through interactions

Participants discussed how interacting with others facilitates learning about sexuality and relationships. Friends were often mentioned as being important in learning about sexuality and relationships, as learning could be achieved by hearing others’ perspectives and experiences of sex, and through practice with others. One participant elaborated,

The greatest need lies in being able to understand yourself and others I think. I have a rather good idea about how I experience (things), how I am and so on. But it is very difficult to know how it is with others. Maybe you have a couple friends you talk with, who tell you how they feel and who you can reflect on things with. It’s really interesting to know, but it’s also important to be able to understand other people and be respectful. (Interview 7, man, age 19).

Participating adolescents felt a need to understand themselves and others. They could learn from friends by discussing contraceptives, sexual identity, sexual preferences, and relationships. When discussing sexual orientation one participant explained,

We talk about each other’s sexual orientation. It is something on the agenda, that you sit and talk about. Of course, it’s more accepted now, and a few have actually come out, so of course you ask yourself, what do I like. It’s not always completely one hundred percent, and it’s really nice to have someone to talk with. (Interview 7, man, age 19).

Participants often chose those who are closest to them when seeking information and support and they often began by confiding with friends. What they saw as important when seeking support from others included feeling comfortable, security and trust, confidentiality, having a good relationship with the other person, and openness to talking about sensitive issues. Being taken seriously, not being laughed at, and talking to someone willing to listen were also important when confiding in friends.

Participants felt that as adolescents, they can indirectly influence each other. This could include being negatively affected by your friends causing you to brag about your sexual encounters. Participating men also believed that it is common to compare genitals with each other, creating ideals about penis size. They believed that they are judged by female sex partners for this, which caused insecurity.

It was experienced to be more difficult to talk with someone you are attracted to, with someone in the same friend group as the person you are attracted to, or with someone, you feel that is too close, despite having a trusting relationship with that person. Other hindrances listed were being shy, embarrassed, or feeling uncomfortable. Also, being unaccustomed to, unwilling, or afraid to talk about sensitive issues, or not knowing where to turn to for support was mentioned. Some participants were afraid to go any further in seeking support when they did not get answers from their friends. One man stated, “I might be able to handle it on my own and I can wait” (Interview 6, man, age 20).

The family was also seen by some as being important for how relationships are viewed. Participants thought that parents should talk to their children about relationships. In the following excerpt the family is stated as a source of support:

It’s really important I believe, even if you get really good information about sexuality and relationships and so on, there is so much that is individual at the same time so it probably always comes with the need to discuss and talk about with friends, and also family, with those who know about it. (Interview 8, non-binary person, age 18).

Choosing who participants turned to depend on the issue at hand, situation, and how pressing their need for support was. They reasoned that one option if friends or other trusted people were lacking, was to turn to a professional whose role is to help others. They also could turn to another adult. They stated that talking to someone and not keeping it all inside was the most important thing, that it felt better to talk to someone. Sometimes they chose to wait a while before seeking support and try to handle the problem on their own. Parents and siblings were sometimes seen as a source of support. One woman explained, “I believe that how you talk with your parents depends on how open you are in the family, some surely have good relationships and can discuss things with their parents, but for others it can be too embarrassing” (Interview 2, woman, age 18).

Another view held by participants was that it is better to turn to another person than to seek support on the Internet. Some participants used the Internet when they did not have anyone else to talk to, or when they were afraid to talk to someone. They explained that the Internet could also be used for online chatting with staff from youth clinics.

Growing through practice and experience

Participants believed that an important step in developing sexuality and relationships came through their own experiences. Experience supports growth and development and leads to self-awareness, learning about sex, and having fulfilling relationships. Coming to terms with your sexual identity could be a process that begins with questioning your sexual orientation followed by a period of lust and curiosity, which results in self-discovery. Participants reported learning about sex through practice and gaining sexual experiences. One participant stated,

You can hear about what others have experienced, but I believe that you have to learn for yourself. So, I believe that it is more than just hearing about something, you have to experience it yourself. I think that this is the easiest way to learn, in any case when it comes to things that can go wrong or that can go well. It’s not the same for everyone, everyone is different. But we learn from adversities, and everything that goes wrong, you don’t know how to act because it is all new. (Interview 1, woman, age 18).

Participants claimed that gaining experience of sex and relationships involved learning through trial and error. For example, how to go about contacting someone you are interested in. Participants often used social media for making contact. One boy experienced contacting someone as challenging due to coming from a different cultural background, with difficulties including language problems and misunderstandings, particularly when writing to someone on social media. Finding a relationship when you felt the need to prove that you are a good person was experienced as more difficult by participants coming from a different cultural backgrounds. Low self-esteem and not feeling good or attractive enough could result in difficulties in establishing a relationship or living up to expectations in a relationship.

The experience of being in a relationship allowed participants to learn to be themselves while adapting to a partner, which involved compromising. Their relationships involved getting to know each other and learning how to resolve misunderstandings, which sometimes led to conflicts. Challenges mentioned included finding out about a partner’s sexual needs and wishes, overcoming difficulties in communication in a relationship, and discussing sex. Being in a relationship where participants were treated badly could affect how they felt. Being in a relationship meant participants had to develop respect for their partner and their partner’s boundaries. Breaking up from a relationship could be experienced as both difficult or easy, depending on the circumstances.

Learning what it means to be ready for sex was considered important by participants. They found it stressful to think about having sex when they were younger and worried that they were the only one who was sexually inexperienced. With experience, they learned that they did not need to become stressed over this. They reported that it was important to feel ready when deciding to have sex. With an experience of sexual activity, participants gained self-awareness of how they feel about sex, and that it can differ from person to person. With experience, new questions arose: “It’s not just obtaining knowledge, it’s what you do with it” (Interview 8, non-binary person, age 18).

Discussion

The aim of this study was to explore late-adolescents’ process of sexual development along with their information- and support-seeking behaviors in a Swedish context. Data analysis resulted in four categories; The desire for knowledge, Discussing norms and attitudes, Learning through interactions, and Growing through practice and experience. Information- and support-seeking behavior was integrated within the different steps in the process. The results showed the interplay of multiple influences on the development of sexuality in late-adolescence. Learning about and developing sexuality can be achieved in different ways, such as interacting with others and though experience. This was also seen in the findings of Michaelson et al. (2015), showing that health knowledge in general is obtained through both didactic and organic learning contexts. Didactic learning includes both formal, such as in school-based health classes or at youth clinics, and informal contexts, such as everyday living situations. Self-reflective experiences, experience of close contacts, observing others, and leaning from the common discourse i.e. beliefs, values and ideas related to health shared by a community, all result in organic learning. This study shows that adolescents form ideas about health through living life, observing other people, conversations, and their own experiences (Michaelson et al., 2015). The results are also in line with Johansson (2016), who suggests a model for formings ones identity which emphasizes interaction, interplay, flexibility and change, during the transitions from late teens to adulthood (Johansson, 2016). This knowledge is highly relevant for teachers and health professionals when working toward sexual health promotion for late-adolescents.

The results show that the need and desire for information and support change as late-adolescents age and develop. As late-adolescents gain experience with sex and relationships, new questions arise, especially in regards to having sex and handling relationships. Several topics were identified that late-adolescents wanted to have more information about and that were missing from sexuality education programmes. Therefore, it is important for teachers in schools to identify gaps to adapt sex education programmes to meet the needs of adolescents. The Swedish government decided on a change in the curriculum for sexuality education and changed the name of the subject to Sexuality, consent, and relationships. The subject will be incorporated into all levels of school education from the autumn semester of 2022 (The Swedish National Agency for Education, 2021). This is a positive step for providing high-quality sexuality education that is relevant to children and adolescents. In relation to the reform, the results of this study could be of value for teacher training programs, to guide them on topics late-adolescents desire to learn more about and incorporate them in their teaching, and aid in developing a more comprehensive sexuality education in schools. Comprehensive sexuality education is part of an essential package for sexual and reproductive health interventions developed by the Guttenmacher-Lancet Commission on Sexual and Reproductive Health and Rights (2022).

Smart et al. (2012) found that late-adolescents choose who to go to for information depending on the specific topic of concern. Factors of relevance were accessibility, complexity, personal relevance, quality, subject matter, and privacy. Health information should be easy to understand, apply to their lives here and now, and be private. Here, healthcare professionals were preferred due to the guarantee of confidentiality. Late-adolescents preferred to seek support from people with whom they felt comfort, trust, and respect, as well as familiarity (Smart et al., 2012). This is in agreement with our findings on how late-adolescents assess different sources for information and support, and how they negotiate who to turn to. According to Unis et al. (2021) building trusting relationships with late-adolescents can be beneficial for conveying a sense of trust, to reach them.

In the current study, Internet and friends were the first places late-adolescents sought information before in some cases eventually contacting a healthcare professional. This is in contrast with a study conducted by Eckstrand et al. (2017) that found that despite using the Internet daily, adolescents did not consider it to be their main source of sexual health information. Eckstrand et al. (2017) found that only about nine percent of their study participants mentioned the Internet as one of their trusted sources of sexual health information. In the current study, the youth clinic’s website was very well-known and commonly used by late-adolescents and was considered to be a reliable source of information. They were also aware that not everything on the Internet can be trusted. For this reason, it is considered important that youth clinics keep their websites up to date with relevant information, and continue to develop their online consultations services, in order to meet the needs of late-adolescents. Also, the topic of the Internet as a source of information should be brought up in sexuality education.

Late-adolescents need support on issues and questions related to sexuality and sexual development and friends were often chosen over parents. Talking about your body, sex, and relationships is seen by some late-adolescents as being a private sphere that they do not want their parents involved in. However, turning to parents for support was an option for some. Those with good relationships with their parents and who believed that their parents had their best interests in mind turn to them for support. According to Ashcraft and Murray (2017), parents are the single largest influence on adolescents when it comes to decisions about sex. They are an important source of information on sexuality and can influence the values and behaviors of adolescents.

Late-adolescents in the present study stated the need to discuss norms and attitudes. Some late-adolescents reflected on how pornography affects norms and attitudes related to sex. Some late-adolescents see accessing pornography on the Internet as a way to learn about how to have sex. However, late-adolescents are ambivalent to pornography and often claim that you need to be critical, that it does not portray reality, that it can affect how you view sex, and that you can become addicted to watching pornography. This is in agreement with a previous study (Mattebo et al., 2012) that showed that adolescents believed that pornography portrayed an unreal image of body ideals, sexuality, and relationships (Mattebo et al., 2012). There is a need for more comprehensive sexuality education including discussions about pornography and how it portrays men and women along with images of sexuality. Healthcare professionals need to be aware of adolescents’ consumption of pornography and also discuss this with them. Adolescents seem to be lacking support from adults in this area (Mattebo et al., 2013).

There is a need for more discussion and sexuality education on LGBTQI people and their lives. Although the acceptance of LGBTQI people has increased in society over time, there is still a feeling of ambivalence and insecurity among adolescents when discussing these issues. Young men in particular could revert to regressive behavior when homosexuality was discussed, and intimacy among young men comes with regulations for body contact and maintaining boundaries (Hammarén & Johansson, 2016). This was also seen in the present study where participants talked about homophobic boys at school who were seen as creating a more difficult atmosphere for gay and bisexual people and their coming out. Study participants also sometimes questioned their own sexual identity and preferences. This is consistent with Johansson (2016)’s findings that adolescents today are actively creating and constructing their own sexuality and transgressing moral and normative boundaries.

Adolescents in the current study had views on the nature of men and women, both reproducing gender roles and questioning them. Masculinity was something that the men focused on, which affected their options for seeking support, in some cases hindering it. According to Johansson (2016), there is a common view of young men that includes repression, power, sexism, homophobia, and being alone in the world. However, there is a growing number of young men who are breaking away from this picture of masculinity and forming one which is more fragile, ambivalent, uncertain, unclear, and formable, where they are more often reflecting, contemplating, and trying to form an adequate masculine identity (Johansson, 2016). This was addressed by some of the men in the study. The participants in the study did not talk specifically about cisnormativity or gender binaries. However, teachers and health professionals need to be aware of this issue when meeting children and adolescents in health care services and in schools. Struggling with questions about sexual identity could be a reason for adolescents for seeking support.

The study’s results show that gender plays a role in support seeking, which is in accordance with previous studies. In the current study, it was taken for granted that women turned to their girlfriends for support, either a group or a best friend. For men, the picture was diverse, some men had a close friend to turn to, while others kept things to themselves and did not seek any support. Some men chose to talk to a woman because women seemed more supportive and it was seen to be more acceptable to turn to them. Seeking information on sexual health differs according to gender and changes with age as sexual activity increases (Whitfield et al., 2013). From the interviews conducted, it seems that men, particularly men from non-Swedish cultural backgrounds, have a need to discuss sexuality and relationships with an adult, and they are more often lacking sufficient support. This need should be addressed to reach this vulnerable group of young men.

The results showed that late-adolescents seek support from healthcare professionals for problems they cannot resolve with friends, or for help with specific physiological needs, such as oral contraceptives or testing for STIs. These visits offer a natural forum for conversations about sex and relationships and for providing sexual health information. Healthcare professionals include nurses and midwives at the youth clinic and school nurses. In Sweden, there are ∼220 youth clinics throughout the country. Adolescents can access them without parental consent and all consults have guaranteed confidentiality. Youth clinics are free and services include testing for STIs, STI treatment, and contraceptive medications and devices, along with counseling (Association for Sweden’s Youth Clinics [Förening för Sveriges Ungdomsmottagningar], 2018). School nurses and school healthcare is also available to all students according to The Education Act (SFS 2010:800, n.d.). In the current study, late-adolescents were growing through gaining experience and achieving self-awareness and experience of sex and relationships. Most late-adolescents reach these goals on their own, but it is clear that there is a need for additional support in the area of talking about issues and questions they are struggling with. Some groups of late-adolescents, such as men who do not have close friendships and those with non-Swedish cultural backgrounds, are in particular need of support.

Our findings can help to increase awareness of the needs that adolescents have for information and support from the perspectives of adolescents themselves, which will aid teachers and healthcare professionals in providing adolescents with up-to-date information related to their needs. It is important that healthcare professionals are visible and easily accessible to adolescents. One way is through participation in sexuality education. School nurses can use their health dialogue to raise issues on sexuality with adolescents and to build trusting relationships with them. Nurses and other healthcare professionals also need to reach out and convey to adolescents that they are knowledgeable on issues related to sexuality and that they are open, willing, and trustworthy sources to turn to.

Methodological considerations

In the data collection, adolescents were interviewed individually, in pairs, or in groups of three. The original plan to just hold individual interviews was changed after requests from some of the students who wanted to be interviewed together with friends. This led to a greater willingness to participate and facilitated the recruitment of participants for the study. Also, the quality and depth of the data gained in the interviews were greater in interviews with two or three participants. However, there is also a risk of bias as students med be affected by their friend's statements. The student pairs were close friends and felt secure with each other, which could open for them to speak more freely. This was also recognized by Kvalsvik and Øgaard (2021) who mean that dyadic interviews promote a sense of security. Other advantages to dyadic interviews reported by Lohm and Druzenko (2013) are minimizing the asymmetry of power in the interview situation and reducing some discomfort that some can experience in individual interview situations (Lohm & Druzenko, 2013). On the other hand, Kvalsvik and Øgaard (2021) stated that a drawback in dyadic interviews is the risk of domination by one of the participants within a dyad, by constantly talking, or dismissing the other participant. This was, however, not experienced in the dyadic interviews in this study. Morgan et al. (2016) mean that dyadic interviews share the same advantages as focus groups in relation to the interaction between the participants. Another limitation of the study could be the small sample of young people in late-adolescence. However, living in a globalized world, there could be a good level of transferability in the results.

The men who participated in the study may not have been representative of all men. Men in general have been reported to have difficulties in talking about emotions and sensitive topics (Clark et al., 2018; Danielsson et al., 2011; Lynch et al., 2018; Rice et al., 2018). The men in the study could be representative of those who are questioning norms related to masculinity and who feel more comfortable talking about the subject. None of the men were interested in sports, for example. The participation of the men could also have been affected by the fact that the researcher conducting the interviews was male.

Future research

Future research could study the effects of the school reform in Sweden with the new subject Sexuality, consent, and relationships in schools. More research could focus on didactic methods for education on sexuality and relationships. Research also needs to stay up to date with the world in which adolescents and emerging adults live in relation to sexuality and relationships, and to study the changes taking place in society and how this can guide professionals in their work with promoting sexual health.

Conclusion

The results showed the path taken by adolescents in their sexual development related to developing their own sexuality and relationships along with adolescents’ information- and support-seeking behavior during their development. Because of the changing needs of late-adolescents in a society which is constantly changing and diverse, it is important for nurses, school nurses, and midwives at youth clinics and other healthcare professionals in different contexts, as well as teachers in sex and relationship education, to have up-to-date knowledge of the needs of adolescents with regard to sexuality knowledge and support. They must also be aware of the conditions for seeking support and be more visible and accessible in schools, which are where late-adolescents spend a large part of their time, and covey that they are knowledgeable and trustworthy sources for providing support on issues related to sexuality and sexual health.

Additional information

Funding

This study was funded by Karlstad University and Region Värmland.