‘They say “I did it”, but they don’t say “I got an STI from it”’: Exploring the experiences of youth with a migration background with sexual health in Amsterdam, the Netherlands

ABSTRACT

Youth with a migration background are underserved by sexual healthcare. Insight in their experiences is essential to develop tailored services and counter disparities. We explored how youth with a migration background access sexual health information, experience public sexual healthcare, and navigate sexual health in their particular sociocultural contexts. We carried out nine semi-structured interviews and one group interview with twelve young people (18–24) with a migration background in Amsterdam, the Netherlands. Respondents were heterosexually oriented and of various sociocultural backgrounds. Data were analysed using thematic content analysis. Three themes emerged: ‘Access to sexual health information’, ‘Access to primary sexual health care’, and ‘Strategies for sexual self-care’. Youth sought out information online or from peers, however, conversations mostly focussed on pleasure while risk was often not discussed. Youth valued anonymity when accessing sexual healthcare, and used several strategies, such as staying silent or adhering to values such as ‘self-respect’, to navigate sexual health within their everyday gendered environments. While these strategies manifested as sources of empowerment, they also resulted in potential vulnerabilities. To counter sexual health disparities among youth with a migration background, public sexual health services should provide culturally safe care and foster participatory collaborations with local stakeholders.

KEYWORDS:

• Sexual health
• youth with a migration background
• sexual agency
• public health services
• access to care

Introduction

The Netherlands is becoming increasingly ethnically diverse. In Amsterdam, the largest city in the Netherlands, 35 percent of the population consists of people with a migration background (Hylkema et al., 2018). As a result, there is a growing diversity in healthcare needs and expectations, including sexual health care (Napier et al., 2014). Sexual health is specifically relevant among young people, because young age is considered a risk factor for adverse sexual health outcomes (Wellings & Mitchell, 2012). In order to achieve good sexual health amongst young people, tailored sexual health services are essential (Bearinger et al., 2007; Tylee et al., 2007). Although universal access to sexual healthcare irrespective of someone’s ethnicity or migration history is a fundamental human right (United Nations, 2016; Vulpiani et al., 2000), research points out that social and cultural factors in the lives of ethnically minoritized youth might affect access to and quality of sexual health services (Baroudi et al., 2020; Hach, 2012). In this paper, we use the term ‘youth with a migration background’ to refer to Dutch youth of colour who are minoritized based on their ethnic background and (family) migration history. The Netherlands prides itself as a foreigner-friendly and racism-free nation, and despite its colonial history values such as tolerance and openness have shaped white Dutch national identity (Wekker, 2016). However, this self-image has long obscured the everyday, structural racisms that are firmly institutionalised within Dutch society (Essed & Hoving, 2014; Turcatti, 2018). Although recently the Black Lives Matter movement has mainstreamed the discussion around white cultural dominance and social inequalities, this conversation is only slowly trickling down into Dutch healthcare institutions, and as such has not yet lead to the widespread implementation of equitable policy measures in practice despite the availability of evidence that racial bias is thoroughly embedded within our system (e.g. Bakkum et al., 2021; Essed, 2005; Helberg-Proctor et al., 2019). Hence, throughout this paper, we understand the experiences and everyday realities of youth with a migration background to be shaped by the socio-political implications of their structural positions as members of racialized and minoritized groups.

Evidence suggests that youth with a migration background are currently underserved by sexual healthcare (Baroudi et al., 2020; J. R. Botfield et al., 2018; Wray et al., 2014) and at higher risk for adverse sexual health outcomes (Newton et al., 2013). In the Netherlands, multiple studies have reported disparities between youth with a migration background and native Dutch youth in, for instance, sexually transmitted infections (STIs) (Matser et al., 2013) and abortion rates (de Graaf et al., 2017; Wijsen & Rademakers, 2003). Several explanations for these disparities exist. For instance, they might result from underuse of sexual health services caused by barriers at the patient and provider level (Botfield et al., 2018; Manderson & Allotey, 2003; McMichael & Gifford, 2009). Youth might lack awareness of sexual health services, or might avoid using these services because they are considered inappropriate or shameful based on taboos that exist in their communities (Botfield et al., 2018; Cense, 2014; Cense & Ganzevoort, 2017). In addition, underuse might be caused by reduced sexual health literacy as a result of the impact of structural marginalisation (Metusela et al., 2017; Svensson et al., 2017). Finally, providers might lack awareness or skills to adequately account for socio-cultural factors in provider-client interactions, which impacts the effectiveness and quality of care for this group (Botfield et al., 2017). Lack of culturally sensitive sexual health promotion and education, both inside and outside the consultation room, could result in youth with a migration background to not benefit as much from these interventions as their native Dutch peers (Fenton, 2001; Khoei & Richters, 2008; Rechel, 2011).

Although globally the body of work on sexual health care needs of youth with a migration background is growing, qualitative research into factors that influence access to care in the Netherlands is scarce. Recent studies investigated differences in youth’s sexual and reproductive experiences, behaviours and health status in the general population (de Graaf et al., 2017), or explored identity, morality and meaning making across different sociocultural environments (Cense, 2014; Cense et al., 2018; Cense & Ganzevoort, 2017). However, little information exists about youth’s experiences with access to sexual health care, in particular with public health-oriented walk-in services such as offered by the municipal outpatient clinics, which provide low or no-cost care, such as STI testing, and for which no referral from a general practitioner or parental consent is required. This lack of insight obscures adequate evaluation of a public health service that is organised around the targeting of health inequities (O’Donnell et al., 2016). To develop tailored sexual health services and provide equitable sexual health care for youth of all backgrounds in the Netherlands, it is important to explore how youth with a migration background experience access to public sexual health care, how they access sexual health information, and how they navigate sexual health in their particular sociocultural environments. Such insights could contribute to a more comprehensive understanding of current barriers to sexual health care, as well as sexual health care needs among this group.

We carried out our study in Amsterdam, a city with over 180 different nationalities and historically well-known for its progressive policies around contested public health issues such as recreational drug use, sex work, and HIV/AIDS and STI care. The capital’s public Health Service includes a sexual health clinic with three auxiliary branches in other neighbourhoods, and provides free sexual health services to youth in the greater Amsterdam area; therefore, our inquiry focussed on youth’s experiences with access to this particular conglomeration of clinics. In addition, based on internal assessment of visitor data, this clinic’s administration has voiced concerns about the relative underrepresentation of youth with a migration background among their clients, which prompted the need to gain more insight in potential underlying factors at the institutional and client level.

Although our use of the term ‘youth with a migration background’ implies categorical homogeneity, we acknowledge that this group is in many ways profoundly heterogeneous and by no means culturally and experientially cohesive, and that within-group variations might be as large or larger than between-group variations. However, the exploratory nature of this study necessitated a broad sample while at the same time, a migration background as well as racial marginalisation has been described as a predictor of increased sexual health and public health risk (Wellings & Mitchell, 201; Devakumar et al., 2020). Therefore, whilst fully recognising the complexity of youth identities and the challenges that emerge when using reductionist categories in health research, we hope this research contributes to current knowledge of equitable access to sexual health services for young people of all backgrounds.

Methods

Design and setting

We carried out an explorative qualitative study to examine experiences of youth with a migration background with access to sexual healthcare in Amsterdam. A qualitative research design is often used in studies that explore the sensitive topic of sexuality because it might lead to more reliable results, particularly in cultural contexts where openly talking about sexuality is uncommon or taboo (Elam & Fenton, 2003; Green & Thorogood, 2018; Wellings & Mitchell, 2012). Throughout Amsterdam and as a result of post-colonial geospatial policies, citizens from different ethnic and socioeconomic backgrounds are unevenly distributed across the major neighbourhoods, which causes segregation along sociocultural lines. For instance, the Nieuw-West (New West) district is home to a large community of people with Moroccan and Turkish backgrounds, whereas in the Zuid-Oost (South East) district many citizens have Surinamese, Dutch Caribbean or sub-Saharan African roots (Hylkema et al., 2018).

In the Netherlands, primary sexual health care is provided by general practitioners, as well as by the outpatient STI clinics of the municipal Public Health Service. The Amsterdam STI clinic provides subsidised care and is the only clinic in the city that provides primary sexual health care free of charge to clients under 25 of all genders and sexual orientations. In addition to usual STI care, the clinic offers consultations on sexuality issues and preventative sexual health care, and carries out scientific research, local health promotion campaigns, and small scale education programmes (Kroone, 2018). In addition to the main building located in the city centre, the clinic has three branches serving clients in the suburbs of Amsterdam: Noord (North), Nieuw-West and Zuid-Oost. Each of these centres is located within a multifunctional community centre with facilities such as a library and youth programmes. The research project described in this paper originated as part of a larger initiative of the Amsterdam STI clinic to evaluate and improve strategies to better tailor their programmes to youth with a migration background, including social media strategies.

Sexual agency

We interpret our findings through the lens of sexual agency. In sexual health research, the concept of sexual agency has been used to understand how individuals and communities navigate the expression of their sexuality in various sociostructural contexts (Bell et al., 2017; Levin et al., 2012). Sexual agency has explicitly been articulated as a departure from the neoliberal autonomy construct, which detaches the notion of liberty and choice from its relational roots, and cements it in enlightenment discourses of individual and inalienable rights, rationality, and moral superiority of the white, cisgender male citizen in the Global North. As a conceptual framework, sexual agency creates space for subjectivity by understanding the body not as a passive recipient of hegemonic sexual scripts, but as an active agent in the emergence of new scripts (Tolman, 2012). Agency, thus, could be understood as a capacity for action and transformation, and as mutually constitutive with the social environment. As such, agency as a theoretical lens allows for the identification of new knowledge about the sexual body, its context, and the power dynamics that underlie the relationship between the two (Cense & Ganzevoort, 2017). In addition, it allows for a more nuanced understanding of how people employ strategies to nurture complex relationships and develop a ‘socio-sexual self’.

In this paper, we use Cense’s, 2019 model of sexual agency of young people to explore ways in which our respondents navigated their sexual health, in particular in relation to access to and interpretation of sexual health information, access to the Amsterdam STI clinic, and sexual self-care (Cense, 2019). Cense models agency as a multidimensional framework that consists of four distinct but interrelated components: embodied agency, bonded agency, narrative agency, and moral agency. Embodied agency refers to the physical, emotional and social experiences of identity, desire and practices as occurring within the possibilities and confinements of youth’s everyday sociocultural realities. Experiences of the embodied agency are infused with gendered norms, and reflect youth’s meaning making from sexual and sexualised interactions. Bonded agency captures relational strategies and activities used by youth to account for social expectations, such as family rules and traditions, and to foster connectedness to different sexual cultures. Narrative agency is defined by Cense as ‘(…) the capacity to weave a life story that makes sense to the individual self’ (Cense, 2019). Cense demonstrates how youth draw on the dominant, sometimes negative and often conflicting stories about sexuality that surround them to construct their own narratives. Moral agency refers to youth’s positioning of themselves within a moral framework. This type of agency models the responsibility toward family and community that youth feel, and the moral meaning making surrounding the negotiation between individual desires and dominant social discourses (Cense, 2019). Finally, because sexuality and thus sexual agency is inherently gendered, we also apply a gender lens to analyse young people’s experiences (e.g. Branković et al., 2013).

Participants and recruitment

We interviewed young people of colour (18 and older) with a migration background who lived in the Amsterdam districts of Zuid-Oost or Nieuw-West at the time of the study. Because of the explorative nature of our study, we used a combination of non-probability purposive sampling and snowball sampling to recruit our respondents; we aimed for a sample with respondents who shared a common characteristic of being of colour and having a migration background but were of various genders, ages, national and regional backgrounds, religions, and education levels (Frambach et al., 2013; Green & Thorogood, 2018). In addition, we aimed to recruit respondents with and without experience with visiting one of the Amsterdam STI clinics. Youth were recruited with the help of nursing staff working at the Zuid-Oost and Nieuw-West branches (access facilitated by the first authors’ contacts at the clinic) and through youth workers at youth centres and school medical officers (access facilitated by the local public health networks of three of the authors, CM, EB and KY), who distributed the information letter and facilitated meetings with youth interested in participating. All respondents were informed of the study’s purpose and procedures prior to the interview through an information letter. Respondents were informed that their participation would result in recommendations to improve care provided by the STI clinic, that their interviews would be handled confidentially, and that the research results would be translated into an anonymized report; in addition, respondents were informed of the voluntary aspect of participation and their right to withdraw at any time during the research process. All respondents gave their written informed consent before they were interviewed. Ethical approval was obtained by the medical ethics committee of the Amsterdam University Medical Centre.

Data collection and quality procedures

Between November 2019 and February 2020, we carried out nine semi-structured interviews and one group interview (N=3) with a total of twelve young people of colour with a migration background. Interviews were conducted by the first author (FdG), who is a native Dutch, white, cisgender female in her late twenties and at the time of the study was pursuing a Master’s degree in clinical medicine. A research dairy was kept during the research project for personal, methodological and theoretical reflections (Green & Thorogood, 2018), and the first author’s position as a staff member at the STI clinic was disclosed before each interview. Youth were interviewed in private at the STI outpatient clinic and at youth centres. To facilitate rapport building, the first author started each interview emphasising there were no right or wrong questions, and respondents were free to not answer a question. Interviews started with a carefully worded question focused on meta-communication to align the expectations of both the interviewer and the respondent and to assess youth’s comfort level before proceeding to topics on sexuality. Topics included experiences and needs in sexual health care, sexuality in personal life, experiences with access to sexual healthcare and sexual health information (including experiences with visiting the Amsterdam STI clinic and ideas about the clinic’s social media campaign), and suggestions to improve inclusivity of sexual health care. Additionally, youth could ask their own sexual health questions, and received a 10 euro gift voucher as compensation. Interviews lasted approximately 40 min. All but one respondent consented to audio-recording. Recorded interviews were transcribed verbatim and de-identified in choosing pseudonyms to ensure anonymity of the participants. To enhance credibility, member checks took place with the majority of the participants (Frambach et al., 2013). To gain more in-depth contextual understanding, the first author made field notes throughout the research process, and formally and informally talked to sexual health experts of different cultural and professional backgrounds.

Data analysis

Data collection, analysis and interpreting took place with an iterative approach to increase dependability (Frambach et al., 2013). Adding codes to the separate transcripts and field notes allowed us to perform a thematic content analysis, which included open, axial and selective coding (Boeije, 2005). The coding was done manually and themes were not determined until the last data were collected (Graneheim & Lundman, 2004). Codes and themes extracted from two transcripts were evaluated by an experienced researcher in qualitative research for intersubjective agreement. Strategies such as looking for repeating topics, ‘in vivo’ codes, metaphors, similarities and differences were used to identify themes in the dataset (Ryan & Bernard, 2003). To understand and interpret participants perspectives, an interpretative approach was used to analyse the data (Ransome, 2013).

Results

Respondents were between 18 and 24 years old. All were unmarried, most lived with their parents, and all respondents spoke Dutch as a first or second language. In addition to their shared Dutch nationality, their cultural backgrounds varied: respondents identified as Dutch-Moroccan, Dutch-Turkish, Dutch-Surinamese, Dutch-Chinese, Dutch-Filipino, Dutch-Dominican and Dutch-Ghanaian. All but one respondents were born and raised in the Netherlands, and all had at least one parent with a migration background. There was variation in educational level and religious beliefs. None of the respondents explicitly identified as other than heterosexual or cisgender, and all explicitly described heterosexual attraction and behaviour. Some were explicit about having had their sexual debut, others did not reveal this information. Finally, eight out of 12 respondents had experience with the Amsterdam STI clinic. The characteristics of the respondents are listed in Table 1.

Table 1. Characteristics of respondents.

Pseudonym	Age	Gender	Cultural background*	Religion	Education	Sexual behaviour	Sexual debut	Experience with STI clinic?
Mohammed	23	Male	Turkish (both parents born in Turkey )	Islam	HPE	Heterosexual	Yes	Yes
Xian	23	Male	Filipino (both parents born in Philippines)	Catholic	HPE	Heterosexual	Unknown	Yes
Xue	24	Female	Dutch-Chinese (father born in Netherlands, mother born in China)	None	HPE	Heterosexual	Yes	Yes
Fatima	20	Female	Moroccan (both parents born in Morocco)	Islam	PVE	Heterosexual	No	No
Karima	22	Female	Moroccan (both parents born in Morocco)	Islam	PVE	Heterosexual	No	No
Yasmina	23	Female	Moroccan (both parents born in Morocco)	Islam	UE	Heterosexual	No	No
Shirley	18	Female	Surinamese-American (mother born in Suriname, father born in the United States)	None	PVE	Unknown	Unknown	Yes
Kyra	20	Female	Dominican (respondent and parents born in the Dominican Republic)	Catholic	PVE	Heterosexual	yes	Yes
Younes	19	Male	Moroccan (both parents born in Morocco)	Islam	SGSE	Heterosexual	Unknown	No
Indra	24	Female	Surinamese (both parents born in Suriname)	None, raised within Hindu tradition	UE	Heterosexual	Yes	Yes
Yazid	22	Male	Ghanaian (both parents born in Ghana)	Christian	PVE	Heterosexual	Yes	Yes
Chayenne	23	Female	Surinamese (both parents born in Suriname)	Catholic	HPE	Heterosexual	Yes	Yes

*All respondents were born in the Netherlands unless otherwise indicated.

HPE= Higher professional education, PVE= Post-secondary vocational education, UE= University education, SGSE= Senior general secondary education.

Three themes emerged from the data: ‘Access to sexual health information’, ‘Access to primary sexual health care’ and ‘Strategies for sexual self-care’. These themes will be discussed below.

‘We don't really use Google for that’: Access to sexual health information

Throughout the interviews, youth described experiences with access to sexual health information. They distinguished formal sexuality education, which in the Netherlands is routinely offered in high school curricula, from informal information exchanged between peers or accessed through the internet. They also talked about whether and how sexuality and sexual health was discussed within their social environments, including valuable friends and parents.

The sources of information youth had access to played a role in their perceived sexual health knowledge. Although some remembered their high school sexuality education classes, most respondents said to have never received any formal education or remembered little of it. Those who did recalled giddiness and jokes. Xian (23, male): ‘[We were] laughing rather than taking it seriously, at that age’. Others had received incorrect information from teachers, such as not being able to get an STI from someone who ‘looks clean’. Although some respondents said they had been too uncomfortable or embarrassed to pay attention in class because of felt taboos about sexuality, most agreed that formal sexuality education was important, also because not all of them discussed sexuality at home, or because they knew of others who had their sexual debut at a very young age. Younes said he had been more uninformed than his friends because of his sheltered upbringing:

[Some] boys start having sex when they are ten years old. But when I was that age I did not even know what the difference was between a dick and a vagina. (…) At some point you have biology in school and learn everything. (…) Some boys were outside a lot and then [they were] raised by the street and the people around [them]. (Younes, 19, male)

Youth suggested ways to improve sexuality education for students who are uncomfortable. For instance, one respondent suggested giving students written information, so they can read it in their own time. Others suggested that separating boys and girls could help create a more relaxed atmosphere.¹ Fatima emphasised prioritising education about STIs over subjects such as menstruation and personal hygiene, because of the preventative effect of fear. She explained:

As a child, if you hear about STIs, you will develop a fear of them. You’ll think, I'm not going to [have sexual intercourse]. But if you learn about this after you have had sexual intercourse with someone ten times, it’s too late. (Fatima, 20, female)

Youth’s informal sources of sexual health information included the internet and their friends. Although most respondents mentioned the internet as a main source, especially when it came to more ‘serious’ information, some did not consider it a trusted one. Several respondents said they would learn more about sexual health from what they witnessed around them. Yazid (22, male) pointed out: ‘We all know someone who is a teenage mother. (…) You hear about that experience, and that’s how you get informed. We don't really use Google for that’. Another male respondent agreed: ‘Unless [you start having complaints], then you Google it. But we don’t look up information beforehand. You just hear it [from others]’. Although other people’s pregnancies and STIs were mentioned as examples of ‘risk warnings’, both male and female respondents said conversations with friends mainly focused about positive aspects of sexual health, such as pleasure:

I’m honestly saying I talk about it often. With cousins and girlfriends. They’re all married. (…) There are no men there, so we talk about everything and more. (…) But we don’t talk about STIs, actually, to be honest. No, but that’s not necessary. Because you know [you have an exclusive partner]. (Karima, 22, female)

In one group they talk about how good it is, in the other group how often they did it. And in another group you hear how to do it. (..). No one is really open. We don’t go so deep. (Yazid, 22, male)

Younes (19, male) had religious motivations to consult his social environment about sex: ‘Because I’m religious, right? (…) So I try to get information from someone who is close to me in that way’. Xian (23, male) shared that he himself is a source of information for others: ‘[To] colleagues who are young [I say], you have to do it safely. Unless you are absolutely sure [you and your partner are exclusive]’.

Youth’s experiences with getting information from parents or family members varied. While some preferred talking to strangers, others had straightforward parents, such as Indra (24, female): ‘Usually my mom starts the conversations, like do you have a boyfriend, how is your boyfriend. When I had my first boyfriend, she asked “Are you safe, are you doing things you want to do?”’ One respondent would only ask her mom for advice when she became sexually active, after marriage:

Because my mom, she does talk about [sex]. Because when she talks with my cousins about it, when they get married, she tells [them] what it is like, what [they] can do better, what [they] should pay attention to. But why would I randomly start talking about it when I don’t have sexual intercourse? (…) I would only talk about it when it is necessary. (Karima, 22, female)

Only female respondents mentioned talking about sexuality with parents, most often with mothers, although Xue (24, female) said she rather talked to her native Dutch dad than her Chinese mother. Both male and female respondents said they would not talk to their dads, although Kyra mentioned it would be important:

I think it is important that dads talk to their children. And let them know what [sex] is. (…) You need to (…) have a connection with them. (…) If something goes wrong, they can just talk to you. Some kids are quite afraid of their dads, so then it gets difficult. (Kyra, 20, female)

Finally, youth had a lot of unanswered questions around ‘normal’ sexuality, sexual behaviour, and risk, including questions about their own bodies and STIs. Some male respondents mentioned concerns about the size of their penis, ‘normal’ time to ejaculate and how to satisfy their partner. Youth wanted to know how STIs spread, whether HIV causes infertility, or why STIs need to be treated when there are no symptoms. Xian (23, male) had heard from someone STIs can transfer from parent to child. He estimated his risk to be low, but decided to get tested just in case:

I heard STIs can be transmitted from your parents to yourself. […] If the parents have an STI, the child also gets it. […] But my parents are really old-fashioned. They had never been with anyone else before ending up together, so I assume I didn't get anything from them. (Xian, 23, male)

‘It could be your sister’: Access to primary sexual health care

Youth shared their experiences with formal sexual health care in the city. Most had visited either their general practitioner and the STI clinic before with sexual health questions. Several of the eight participants who were recruited at the STI clinic had heard about the clinic through friends, and one was referred by her general practitioner. Some had been to the clinic multiple times. When asked about how he talks to his friends about getting tested for STIs, Mohammed (23, male) said: ‘Yeah, then you say [to each other] hey, drop by just to be sure’.

The respondents who had visited the clinic reported overall positive experiences. They described a welcoming and quiet environment, low costs and quick test results. Xian (23, male) appreciated the easy-to-find location: ‘I received an email with the route and a description of the building. I liked that, because I didn't want to just walk into the wrong building’. Most had understood before their visit that an STI test would be free of charge, but lacked other information such as details about test procedures. Two male respondents remarked they had heard that testing involved getting their urethra swabbed with a q-tip. Another respondent was critical of the amount of effort it took her to make an appointment online, which led to a delay in help seeking.

All respondents, male and female, shared questions and concerns about anonymity and confidentiality. Youth who had not been to the clinic wondered if they needed to show their passport, and if their visit would be registered in their medical file. During an informal conversation at a youth centre, a young boy asked the first author, worried: ‘But they won’t tell my parents, right? Nothing, just nothing at all, no letter, right? (…) Are you sure, hundred percent sure?’. Anonymity was particularly of concern in relation to being recognised by an acquaintance or family member, because, as some explained, that would evoke feelings of shame and discomfort. Xue (24, female) said, hesitantly: ‘I don’t know … It is more the shame or something that pops up. And then you think what are you ashamed about. Everyone has sex. But yes, shame comes up’. As a result, some respondents preferred attending a clinic in another district rather than one close by. Xue felt that going to her general practitioner was not a good alternative. She explained: ‘My general practitioner knows me personally (…). [At the STI clinic] you talk to someone you don't really know, so I'm more comfortable ‘. Youth’s shared preference for anonymity also showed up in their hesitation to talk to a sexual health provider face to face. Several said to prefer an online chat consultation. In case face-to-face consultation was necessary, to some the cultural background of the healthcare provider was an important factor in feeling comfortable. Almost half of the participants indicated to rather talk to a provider with a different cultural background from their own. Yasmina articulated:

Actually it would have the opposite effect [to talk to] a provider with the same cultural background. We always say: “It could be your sister”. Not in terms of real family […] but it would be awkward, it would be too close. (Yasmina, 23, female)

However, others were indifferent about the background of the provider, and one respondent preferred a provider with the same background because of being able to speak her native language. Finally, after talking to Younes (19, male) at a youth centre, one of his friends wondered if he was welcome at the clinic. Using the Dutch words autochtoon and allochtoon,² he asked the first author: ‘Do allochtonen also visit the STI clinic? Or only autochtonen?’.

‘If you touch me, you’re in trouble’: Strategies for sexual self-care

Youth shared several ways in which they navigated caring for their own sexual health (including pleasure and protection from STIs and violence) in a context of diverging and gendered community norms around sexuality.

Some respondents experienced tension between their own values and those of the people around them, such as family members, or oscillated between their traditional culture and mainstream Dutch youth culture while embracing both; others did not experience such tension at all. Whether youth experienced tension was independent of the direction of their particular values, but rather related to the space they experienced to express these values. Yasmina (23, female), who grew up with the norm to wait with sex until marriage, did not feel conflicted: ‘For me it’s no issue, because I don’t know any better’. So did Indra (24, female), who explained that her norms and values deviated from her parents’ because she was born in the Netherlands: ‘It’s not like if my child turns out to be gay, a bomb goes off’. Chayenne said it was her mother whose attitude towards sexuality had changed, which had allowed her to more easily balance family rules with personal desires:

I noticed my mom became more relaxed. I saw that if I really needed to, I could come to her. (…) [In the past] even if it was an innocent crush, I shouldn’t have come knocking. (…) [My mom] also had to change, in terms of letting go of her culture. (Chayenne, 23, female)

However, both male and female respondents said the messages about sexuality they received at home were not always congruent with their everyday realities, which involved experiencing desire, being confronted with dominant Dutch youth culture, and sex on social media. Several respondents even explicitly distanced themselves from the ‘hook-up’ culture they said was common among young Dutch people of all sociocultural backgrounds. Indra (24, female) said that ‘ … everyone is just after that one thing’, which made her insecure. Younes observed an emergent morality among younger generations of traditionally raised youth. He reflected:

When I ask [older boys who are actively practicing their religion] what did you do [when you were young], they might say, the worst thing I did was maybe a kiss on the mouth. But this generation: hotels with laughing gas and, I don’t know, clothes off … it’s a different level. (Younes, 19, male)

At the same time, respondents acknowledged that in this sexualised context, aligning personal needs with traditional standards is not always easy. For instance, Younes and Mohammed explained that successful alignment had consequences. ‘Look, I know I am not perfect. I’ve had girlfriends, I have a girlfriend now’, Younes (19, male) reflected. Mohammed reflected on the ‘clash’ between his private and public actions, but felt no moral tension:

It is difficult to keep it up until you’re married. You go on holidays, meet girls, nice company, just name it. (..) Well, it clashes with the values you promote to others. Like, I stand for this but you don’t stick to it yourself. Not that [I] struggle with that, like I did this and that. No, I don’t. (Mohammed, 23, male)

Respondents also talked about ways in which youth could engage in sexual activity while still meeting expectations. The most-often mentioned strategy was keeping quiet and staying unseen. Respondents explained that both boys and girls were silent about their sexual activity, but in different ways. Younes (19, male) said boys dated girls from other towns to stay out of sight: ‘There are boys who have a girlfriend, they don’t show anything, no one knows about it (…). They live in Amsterdam-West, they go to Amstelveen or Hoofddorp³’. Younes explained that boys who show their relationships more publicly negotiate their own and their family’s moral permission through the intention to be ‘serious’ with someone. He said:

I just ride down my street with a girl on the back of my Vespa. (…) A friend of my brother saw me. Which of course is very awkward, but the moment [my brother] asks ‘was it serious?’ and I say yes, and he understands, then you’re good. (…) Maybe you had a girl with whom you did it for like, three years. And you didn’t want it to end up this way, of course you want to end up with this person. (Younes, 19, male)

Even when boys stayed quiet, that did not mean parents did not know. Yazid (22, male): ‘I was raised Christian, so according to the religion you’re supposed to wait until marriage. My parents (…) just know I‘m not a virgin anymore. (..) They just slowly realized’. Mohammed said:

For the second generation, the first children of the labor migrants from the 70’s-80’s, sex before marriage is still taboo. [They] don’t talk to your children about it, because [they] assume they remain a virgin until marriage. (I: Do your parents assume you’re a virgin?) R: no, I don’t think so. (Mohammed, 23, male)

According to Fatima and Karima, who themselves wanted to wait with sex until marriage, silence was effective for pursuing pleasure, but less so for staying protected from STIs or exploitation, because risk was not part of the conversation about sex. Karima explained that girls who are sexually active only trust other sexually active girls: ‘Girls don’t even talk about it to each other. [Only if they both have sex], then she knows [she is] safe because [the other girl] does it as well’. They talked about how this silence effected both boys and girls:

Fatima: [Boys] definitely have sexual intercourse. (..) It’s a taboo either way so you’re not going to say you did it. Let alone if you walked away with an STI. Karima: Yes, but boys do tell each other they did [have sex]. Fatima: They say ‘I did it’ but they don’t say ‘I got an STI from it’. Karima: No, but they don’t know that. They don’t think ‘I might have [an STI], I should get tested’. (Fatima, 20, female and Karima, 22, female)

Fatima: [Online influencers who are escorts] influence young girls. [Girls] think, oh, easy money (…) but one thing leads to another and before you know it you’re trapped. Karima: (…) [girls] need to know there’s a risk. Because you do it with multiple men, and that’s quite dangerous. (Fatima, 20, female and Karima, 22, female)

The gendered aspects of experiences of sexual self-care showed up not only in the use and impact of silence as a strategy, but also in the acknowledgement of the double sexual standard by several respondents such as Mohammed (23, male), who explained: ‘When a boys loses his virginity or has sex with a girl, it’s a good job, and you really are a winner. When a girl does it, it’s like ‘what are you doing?’. Slut, or something’. As a consequence of this double standard, youth perceived girls’ situation as much more precarious than boys’. Yazid (22, male) argued: ‘[A girl can be] vulnerable. She can be a target’. Kyra said she would especially discuss sex with a future daughter because of what she knew about girls’ risk, including her own:

I have girlfriends for whom it just ended badly. And I think [it would not have been as bad] had their dad talked to them. “Don’t let yourself get touched there”, and that kind of stuff. Or “If someone touches you, you have to tell me”. I myself am aggressive, so if you touch me, you’re in trouble. (Kyra, 20, female)

Female respondents discussed how this precariousness impacted their sexual health needs and behaviour. Shirley (20, female) asserted: ‘When I’m seeing someone, I get myself tested. I have to protect myself because I don't know what he’s doing’. Youth emphasised the importance of self-respect for both boys and girls in navigating the double standard and staying healthy. They used the term to refer to personal dignity, to behaviour that would not label you as ‘easy’ or promiscuous, including keeping things to yourself. Younes (19, male) articulated: ‘I think [boys and girls] should look at self-respect (…) and if you really want to reveal private things. Like losing your virginity, it’s kind of a big deal. It’s up to you if you tell others’. Yazid would marry a girl who was not a virgin, as long as she had self-respect:

Look, I’m not a hypocrite. I’ve had sex with someone else before you. If you had too, it is only important for me how it occurred. If you’ve been treated like a piece of trash, or if you were easy, I don’t think that you have self-respect. (…) But I’m not going to judge her for one time. (Yazid, 22, male)

Although youth problematised the double standard, they also accepted it as a reality. As Mohammed (23, male) remarked: ‘It’s not okay, but unfortunately it’s a fact’.

Discussion

We explored how bicultural youth in Amsterdam access sexual health information, how they experience access to public sexual health care, and how they navigate sexual self-care in a social context of sometimes conflicting value systems. We found that formal sexuality education did not always meet youth’s needs. Preferences for when and from whom to collect sexual health information depended on individual and group values. Anonymity and confidentiality were considered important criteria for access to public sexual health services. Youth valued explicit, tailored and accessible online information about services and procedures, including privacy procedures. Finally, youth employed a range of strategies for sexual self-care to negotiate social expectations and moral positions with everyday experiences.

Multiple sources of sexual agency

The respondents in this study used several strategies to negotiate their sexual health (both risk and pleasure), such as seeking information from trusted informal (mothers, friends) and formal sources, seeking STI testing, abstinence, rejecting hook-up culture, distancing oneself from parental values and expectations, staying silent and/or unseen, not striving for moral perfection, intending to marry a sexual partner, and using concepts such as self-respect to set behavioural boundaries. The particularities for this navigation depended on the way in which their social environment, in particular their families, provided the conditions to align their individual values and desires with social expectations. Our findings are in line with previous research from the Netherlands. Cense (2014) argues that youth with a migration background who feel connected to their community often express various sexual strategies in order to affiliate with different social groups. These sexual strategies may vary from being fully loyal to their community to breaking away from the norms and values given from home, although most of identified strategies combine these opposites (Cense, 2014). Across themes, the strategies youth in this study employed to navigate sexual health closely connected to components of Cense’s model of sexual agency. Often times, strategies reflected multiple and overlapping types of agency. Self-respect, for instance, was a source of moral agency and as such facilitated bonded agency, but also occurred as embodied agency because it influenced youth’s everyday sexual behaviour; furthermore, as a source of narrative agency it allowed youth to make meaning of the complex pile of sexuality stories, and orient themselves in their social environment.

Although male and female respondents drew from similar sources of agency, the way in which agency manifested in strategies to enhance sexual health was thoroughly gendered and rooted in the double sexual standard. For instance, in accounts where virginity provided embodied and moral agency in staying safe from sexual harm and seeking pleasure within marriage, males who adhered to this value had access to particular strategies (such as ‘intention to marry’) and could silently and uninterruptedly explore their sexuality (and their morality) because they were less likely to experience physical victimisation and social repercussions. At the same time, while female respondents talked about discussing sexuality with a same-gender parent in an act of bonded agency, respondents also indicated that this bonded agency with parents (i.e. dads) was less available to men; in addition, male respondents indicated not proactively seeking (formal) sexual health information which might undermine their embodied agency. Although silence provided a source of narrative agency for both men and women in our study, it also produced different vulnerabilities, in particular in combination with embodied strategies such as having sex with multiple partners and the use of informal information sources; where, our respondents noted, the absence of a risk narrative caused men to expose themselves to STI risk mainly, women exposed themselves to exploitation and pregnancy as well. The double sexual standard and its impact on access to sexual health of people with a migration background has been researched before in the Netherlands. For instance, Salad et al. explored access to HPV vaccination in a Dutch-Somali community and concluded that gendered norms about sexuality reduced women’s access to care and increased their risk to contract HPV (Salad et al., 2015). Hence, our study shows that a context of double sexual standards might produce gendered vulnerabilities despite male and female youth using similar agential strategies.

Promoting empowerment and reducing vulnerability: cultural safety

We argue that in their current contexts, including the health care context, youth’s agency might lead to empowerment on the one hand, and to vulnerability on the other. Empowerment emerges from the potential of specific strategies to seek pleasurable and safe sex. Most youth we talked to had gained access to the STI clinic, despite logistic, communicative and cultural barriers. At the same time, some strategies might result in increased vulnerability,⁴ specifically the lack of a shared discourse about risk and risk reduction which hinders the development of a shared STI consciousness in communities. Moreover, because of the double standard, the position of girls and women who choose to be sexually active in a context where silence and hook-up culture go hand in hand is especially precarious. Hence, to counter the potential adverse effects of youth’s strategies, it is important that sexual healthcare in the Netherlands removes barriers that prevent youth from benefitting from their agency.

Such barriers, we argue, are largely embedded within the public sexual health institutions. The Dutch healthcare system is built to benefit white Dutch natives, and as such is inherently biased towards youth of colour with a migration background, whose social contexts, communities and everyday experiences might differ from the white cultural norm. Our results show that the Amsterdam STI clinic might be perceived by some youth as a place only open to native Dutch, and that youth might perceive sexual health clinics as spaces where their anonymity is not guaranteed. This, compounded by strategies of silence, undermines youth of colour’s access to sexual health.

Public sexual health services in the Netherlands should therefore actively contribute to youth’s capacity for resilience by striving for a culturally safe care environment that decentralises cultural whiteness, including native Dutch cultural values around sexuality and the white Dutch client as the norm client. Unsafe cultural practice ‘comprises any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual’ (NCNZ, 2011, p. 7). Culturally safe care would entail, for instance, easy-to-find and actively communicated information about confidentiality in various languages, a communication policy aimed at making clients of all backgrounds feel welcome (for instance diverse representation in visual material), and culturally sensitive providers (Botfield et al., 2018; Hällström et al., 2017). At the same time, local sexual health services can facilitate conversations about sexual health risk by providing educational outreach programmes through (youth) participatory projects in the community (Ozer et al., 2020), working in close collaboration with local stakeholders such as youth groups and high schools.

Strengths and limitations

This study has several strengths and limitations. As far as we know, this is one of the first studies in the Netherlands to apply Cense’s model of sexual agency to the experiences of youth with a migration background, and to explore youth’s agency in the context of public sexual health care. Our broad sampling approach allowed us to include youth of various ages, educational levels, cultural backgrounds and experiences in the healthcare system. The age and cultural background of the first author who collected the data and her experience as a sexual health provider might have contributed to building rapport, which could have encouraged youth to share opinions and experiences. However, this study also has limitations. First, most youth were recruited at locations of the outpatient STI clinic, and therefore perspectives of youth who are unaware of the existence of the STI clinic, who manage their sexual health risk independent from mainstream institutions, or who have more conservative views on sexuality might be underrepresented in our data. Second, the explorative nature of this study limits the theoretical transferability of our findings, and the sample characteristics do not allow for an analysis that explores differences between first and second-generation youth with a migration background, even though such an analysis could further orient towards causes of sexual health inequalities. Third, the first author is a sexual health provider and has a sociocultural background different from the respondents, which might have led to socially desirable answers or influenced what youth chose to share. Finally, and importantly, when conducting research into aspects of diversity and health, a big caveat is not to leave the use of analytical categories such as ‘migration background’ undiscussed. In particular, assuming a direct, uncomplicated relationship between a social identity factor and health experiences should always be avoided to not fall into the trap of essentialism, culturalism, and ethnicization of sexuality (e.g. Vieten, 2016; Krebbekx, 2017). At the same time, the explicit use of such categories is sometimes necessary to examine structural roots of inequality and develop more inclusive systems and policies (‘strategic essentialism’, Epstein, 2008; Verdonk et al., 2019). Therefore, more in-depth research is needed to explore the complex relationship between social identity (including white Dutch identity) and access to public sexual health institutions.

Conclusion

Heterosexual youth with a migration background in Amsterdam use various strategies to navigate access to sexual health, which includes negotiating their sexual self-care within their particular sociocultural context to reduce risk and experience pleasure. Youth’s accounts revealed different types of sexual agency. However, in a social context that is profoundly gendered, this agency manifested in sexual health strategies that impacted men and women differently. While strategies such as staying silent about sexual activity foster empowerment, they also potentially create vulnerabilities. To strengthen sexual health resilience of youth with a migration background and combat sexual health inequalities, public sexual health services such as STI clinics should transform toward culturally safe care. Such transformation should include the decentralisation of Dutch cultural whiteness as the norm client.

Acknowledgments

We thank the young people who shared their stories with us. Special thanks to Nazaré Barclay Reinders and Ewout van Luijk for critically reading the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 In the Netherlands, sexuality education takes place in mixed gender classrooms.

2 These Dutch terms refer to people with cultural roots within the Netherlands (autochtoon) and outside the Netherlands (allochtoon); however, in public and political discourse they have been racialized to mean white and non-white. Although the terms are now considered outdated, ‘allochtoon’ is still frequently used, also by people with a migrant background to refer to themselves in relation to the ‘white other’. In some cases the word has been reclaimed by young people of colour.

3 Amstelveen and Hoofddorp are towns near Amsterdam.

4 We use the term vulnerability not as an inherent trait of an individual, but as a circumstance: an increased exposure to risk in a risk environment (4).