Aboriginal young people’s perspectives and experiences of accessing sexual health services and sex education in Australia: A qualitative study

ABSTRACT

Aboriginal and Torres Strait Islander (Aboriginal) young people seek information and access health services for their sexual health needs. This study examined Aboriginal young people’s perspectives on sexual health services and sex education in Australia. Overall, 51 Aboriginal people aged 16–26 years were interviewed by peer researchers in Sydney, Australia in 2019–2020. The findings suggest that the internet was used to assess information quickly and confidentially, but Aboriginal young people questioned its reliability and accuracy. Family, Elders and peers were seen as sources of advice because they had real-life experience and highlighted intergenerational learning that occurs in Aboriginal communities. School-based sex education programmes had mixed reviews, with a preference for programmes delivered by external specialists providing anonymity, clear and accurate information about sex and relationships and positive approaches to sex education, including how to gain consent before sex. There was a need identified for school-based programmes to better consider the needs of Aboriginal young people, including those who identified as LGBTQI + . Aboriginal Medical Services were highly valued for providing culturally safe access to services, while sexual health clinics were valued for providing specialised confidential clinical services with low levels of judgement.

KEYWORDS:

• Indigenous
• First Nations
• youth
• school
• Aboriginal Medical Service

Introduction

Aboriginal and Torres Strait Islander (hereafter Aboriginal) peoples possess a strong sense of community, culture and connection to the Land (Berndt et al., 2018) and view health as a broad holistic concept – which includes the physical, emotional and spiritual wellbeing of a person and their community (Commonwealth of Australia, 2017; Lock, 2007). In 2021, there were an estimated 812,000 Aboriginal peoples in Australia (∼3.2% of the Australian population) and about 150,000 (18.5%) were 15–24 years old (Australian Bureau of Statistics, 2021).

In recent years, some Indigenous leaders globally have advocated for a shift to strengths-based approaches which focus on how people foster health and wellbeing (Askew et al., 2020; Bryant et al., 2021; Fogarty et al., 2018). In research, strengths-based approaches aim to highlight the positive attributes of individuals, families and communities to produce new information for policy, programme development and future interventions (Bryant et al., 2021; Fogarty et al., 2018). Indigenous scholars and leaders in Australia, Canada and New Zealand also advocate for the inclusion of culture and identity as sources of strength and empowerment when conducting research (Barker et al., 2017; Bond, 2019; Eketone, 2016; Greenwood et al., 2018; Jones et al., 2018; Mooney-Somers et al., 2011).

Aboriginal young people want to be sexually safe and healthy (Bell et al., 2020a). Existing qualitative research in Queensland and the Northern Territory documented the strategies that Aboriginal young people used to protect the sexual wellbeing of themselves and others. This included limiting the number of sexual partners, having sex in established trusting relationships, using condoms and access to other forms of contraception, giving condoms to friends, accessing sexually transmitted infection (STI) testing and encouraging peers to do so, attending health services with friends, and encouraging safe sex practices among peers (Bell et al., 2020b; Mooney-Somers et al., 2012). The two studies above identified various barriers to accessing sexual healthcare that were highlighted by Aboriginal young people – including a lack of culturally safe services, ineffective service design for young people, racism and shame. However, existing studies have typically relied on clinical data with a distinct lack of research on Aboriginal people’s perspectives on sexual health services as health consumers (Ubrihien et al., 2022). Likewise, there is a lack of research on the resources that Aboriginal young people draw on to learn about sex. Studies with other young people have highlighted common shortcomings within school-based sex education and show that the Internet was a leading source of sexual health information (Buhi et al., 2010; Pound et al., 2016).

In Australia, an estimated 141 Aboriginal Medical Services (AMS) provide approximately three million episodes of care each year to about 350,000 people (National Aboriginal Community Controlled Health Organisation [NACCHO], 2022). AMS provide a culturally safe environment and are often led and staffed by Aboriginal peoples. In urban areas, AMS can be large and provide medical, dental, and allied health services (NACCHO, 2022), including sexual and reproductive health services. In regional and remote areas, AMS are usually smaller and some only provide medical services (NACCHO, 2022). Aboriginal peoples prefer to access an AMS for their health needs with a study showing that 54% of Aboriginal people aged 16–30 years old had attended an AMS for their health needs in the previous year, compared to 29% who had attended a general practice (Ward et al., 2013).

Most studies about sex and relationships among Aboriginal people in Australia have been based in remote areas, or focused on particular sub-groups, conditions or behaviours, e.g. women, pregnant women, STIs or risk behaviours (Ahmed et al., 2022; Heris et al., 2020; Silver et al., 2015). In contrast, we undertook a study that interviewed Aboriginal young people living in urban areas about their views on sex and adopted a strengths-based approach that considered the role that Aboriginal culture and identity play in Aboriginal young people's lives. This paper examines Aboriginal young people’s perspectives on sexual health services and sex education. While this research is situated in Australia, there are implications for sexual health promotion for young people who identify as Indigenous in other countries, such as Canada and New Zealand.

Materials and methods

Aim and setting

The ‘What we do well: stories of love, sex and relationships’ study was a qualitative study based in two Aboriginal communities in Western Sydney, Australia (Bryant et al., 2018). Western Sydney has large culturally and linguistically diverse populations as well as a large Aboriginal population. The study aimed to explore the sexual decision-making and beliefs of Aboriginal young people and to identify the social, cultural, and personal resources used to achieve positive outcomes. This project used a participatory peer research approach by hiring Aboriginal young people to conduct interviews with other Aboriginal young people (Bell et al., 2021; Dudgeon et al., 2020).

Governance

The study had an Investigator Committee consisting of Aboriginal and non-Indigenous academics and community workers. We also established an Aboriginal Advisory Committee which was chaired by one of the Aboriginal investigators to oversee all aspects of the project including, issues of cultural safety, reviewing and approving research documents, interview questions, recruitment, data collection and dissemination of findings (RB, MB, MD). Aboriginal people were employed as research assistants to work on project management, research training, data collection, data analysis and research dissemination (MB, KG).

Inclusion criteria

To be included in the study, participants needed to be 16–24 years old at the time of recruitment, identify as Aboriginal and/or Torres Strait Islander, reside in Western Sydney and be able to converse in English.

Peer interviewers

Fourteen Aboriginal young people (nine females and five males) aged 16–21 years were recruited as paid peer interviewers (PIs) through local Aboriginal community organisations and health workers. PIs participated in an interactive four-day training workshop with the research team, including sessions about research ethics (e.g. informed consent, confidentiality, risk management), research methods (e.g. recruitment, data management, interviewing skills) and the study themes (so to build familiarity with the topic and encourage probing as per qualitative interviewing techniques). PIs also participated in interviews with same-sex members of the research team as part of their training and this data was included in the study. All interviews were conducted in same-sex pairs to meet cultural obligations associated with men’s and women’s business.

Recruitment

PIs were asked to recruit and interview Aboriginal young people in their local areas. Interviews were conducted during November and December 2019 and July and August 2020. The recruitment period was split into two due to COVID-19 lockdowns and restrictions. Participants were recruited primarily through the peer interviewers’ personal networks (i.e. friends, cousins, siblings, etc.). Each participant received $50 for their time.

Development of the interview questions

The interviews covered three main topics:

1. Cultural strengths for staying healthy: the individual, family, community and cultural strengths and resources that young people draw on to help them reduce their risk and stay healthy;

2. Sexual relationships: staying healthy and solving problems: how sex and relationships are understood, how choices are made and the meanings attached to those choices, and how people stay healthy, protect themselves and solve problems; and

3. Using services and other health education/promotion: perspectives and experiences with sexual health promotion and health care services, and what feels relevant and works well for them.

Peer-led interviews

The peer interviewing method makes use of existing social networks where relationships of rapport and trust have already been established. This has been shown to facilitate a more comfortable and open interview and minimise the risk of embarrassment when discussing sensitive matters, such as sex and relationships (Gomez & Ryan, 2016; Lushey & Munro, 2015). This also enables young people to drive the research on their own terms and talk about the experiences and values relevant to them. Each PI was asked to recruit three participants and conduct three interviews with each of them. Each participant was interviewed three times for about 20 minutes, meaning a total of 60 minutes interviewing time. Interviews were recorded using a digital audio recorder and then transcribed by a professional transcriber working under a confidentiality agreement. Following each interview, debriefing interviews were held between the PIs and the research team and this was also included in the formal analysis. Debrief interviews took between 20 and 60 minutes and allowed the research team to give feedback about interview skills and to monitor data quality. We also created rules when conducting the interviews to minimise risks to participants. These included: (1) using third-person interview techniques (Bell et al., 2021), where young people avoid telling personal stories and describe the general views and experiences of ‘people like them’; (2) no names or other identifying information to be mentioned; and (3) ‘Off Limits’ topics including, sexual assault and sex under the age of consent, which require mandatory reporting under New South Wales law.

Data analysis

We analysed the data using thematic methods (Denzin & Lincoln, 2011) with a focus on strengths (Bryant et al., 2021). Thematic analysis identified themes within and across interviews (Denzin & Lincoln, 2011) and highlighted the collective ways in which participants understand sexual decisions and practices, and their social, cultural practices and beliefs, with a particular focus on the values and practices that young people engage to stay safe and build healthy sexual wellbeing. To strengthen our approach, two researchers did a round of preliminary coding independently from each other to come up with a coding framework which was then reviewed, amended and finalised by the project’s investigator team, which included both Aboriginal and non-Indigenous researchers. Participants’ names have been changed to protect their identities. Data were coded using NVivo 12 (QSR International, 2020).

Ethics

Ethical approval was received from the Aboriginal Health and Medical Research Council of New South Wales Ethics Committee and South Western Sydney Local Health District Human Ethics Research Committee – HREC number: 1441/18.

Results

Participants

Fifty-one Aboriginal young people were interviewed, including the 14 PIs. 49 participants self-identified as Aboriginal only and two self-identified as Aboriginal and Torres Strait Islander. Participants ranged in age from 16 to 26 years with most (82%) aged 16–20 years and two participants’ ages were unknown. Most of the participants lived with family and around half were high school students.

Four themes were identified: (1) The internet as helpful but unrealistic – participants used online resources including pornography (porn) but were always conscious of misinformation; (2) The desire for school-based sex education that goes ‘beyond the basics of just STIs’, and focusses on the relational aspects of sex (e.g. consent, communication and healthy relationships); (3) the high regard given to intergenerational and intragenerational learning through family, Elders and peers, including the value placed on lived experience; (4) the importance of having access to a wide range of sexual health services (including AMS and sexual health clinics) so that young people had a choice about where and how to seek help, and enable their self-determination.

1. The internet as helpful but unrealistic

Information online

Almost all the participants identified the internet as a key tool that young people used to educate themselves about sex. This included websites, discussion forums, social media groups, smartphone apps, online streaming (e.g. YouTube) and porn. Several participants cited internet-based resources as a first port of call when seeking information about sex, sexual health, or relationships.

About STIs, they could go to the Internet to see what the signs and symptoms are, something brief to go off. That would probably be my first option … Typing it in there and seeing what came up. – Will, Male, 18 years old

Participants offered several reasons for using the internet to search for sex-related information. This included the convenience and speed with which they could access information and having a sense of anonymity and privacy. Online anonymity was felt to provide participants with the ability to seek out information without having to experience feelings of embarrassment or the risk of social judgment, especially on particularly stigmatising topics – such as STIs and teenage pregnancy. Some apps allowed young people to actively engage by asking questions about sex and relationships.

… it was an anonymous app where you felt a bit safe to ask questions. Maybe you were too timid to ask people in real life … I used an app to get advice on many things about sex and relationships and health – Madeleine, Female, 20 years old

A few participants talked about young people accessing porn to inform their sexual curiosity and learning – especially regarding the mechanics of sex ‘in practice’ and concerning diverse sexual preferences and tastes.

I didn’t really know how sex worked until I watched porn … I think it is very likely and it is definitely the case that a lot of young people, when they’re unsure about how sex is meant to work and what its meant to look like and what its meant to be, they definitely refer to porn and look at porn as their point of guidance. That can definitely be harmful for a lot of reasons … But also, it can be helpful, as a first point, to be like ‘oh this is generally the gist of things and this is what that is’ – Susie, Female, 21 years old

Navigating misinformation

Participants were aware that information online could be unreliable and inaccurate. They also felt that depictions of sex and relationships on social media and in porn could be inaccurate and misinform younger people who might not have the experience to distinguish between ‘what is real’ and what is unrealistic.

Some of [the information] is fake. Like you don’t know what’s real and you could be reading something and it might not be true. So you have to be careful about what you read online ‘cause it could make you think that you have something when you don’t have it. – Julia, Female, 17 years old

When asked how they determined the reliability of online information, participants described looking at the general design of the website, considering authors’ credentials and website associations (e.g. websites connected to known organisations could be seen as more trustworthy), checking spelling and grammar and considering where information was sourced from and whether it is ‘up to date’ because ‘it is not always updated, it is usually old information’ – Lauren, Female, 20 years old.

• 2. School-based sex education programmes that go ‘beyond the basics’

Most participants saw school as the primary source of formal sex education for most young people. However, perspectives on the quality and effectiveness of school-based sex education varied depending on the content, facilitator and method of delivery.

It was broadly felt that school-based sex education only provided participants with ‘the basics’ of sexual health education and lacked information about the social aspects of sexual wellbeing which could help young people foster healthy sexual relationships. Some participants voiced a need for more comprehensive sex education in schools with a sense that it was often ‘all about the scientific stuff' and too focussed on ‘just the way your body works’ – Ellie, Female, 21 years old. Participants talked about wanting more in-depth education on topics like informed consent, taking care of one’s wellbeing (including mental health), and gendered stereotypes.

I definitely think there needs to be more conversations about the practicalities of having sex. Like, positive consent. They need to introduce those things in earlier and they need to talk more in-depth about you know … combating stereotypes. And that it’s okay to laugh and have a fun time during sex, like it’s not always intense, serious … – Madeleine, Female, 20 years old

Participants expressed a desire to see more education about healthy relationships – including what a healthy relationship looks like, how to foster healthy relationships and what to do if they are in an unhealthy or abusive relationship. Education on relationships was considered important because some young people may not have healthy examples of relationships in their families or communities, and:

at such a young age, you don’t know the difference between a good relationship and a bad relationship. So, if you are in a bad relationship, you’re more likely to just go along with it. – Grace, Female, 23 years old

Several participants thought more education around how to manage concerns and solve problems (rather than just preventing them) would be beneficial.

They need to teach you about how to deal with sex, sex predators, STDs, because that doesn’t really come up – Ellie, Female, 21 years old

Providing participants with information about where they could go to seek help or support (e.g. local services) was seen as important.

They wouldn’t really recommend any health services … But at school, lots of services come in, like maybe twice a year. Services come into schools and just talk about that stuff … They’re often nearby the school and if [young people] want to get more information, they can go there. – Frank, Male, 18 years old

Facilitators of school-based sex education programmes

Multiple participants spoke about sex education being delivered in schools by external facilitators and services as being positive. This was seen as one way that participants could learn about local services that they could access.

So [local sexual health service] came in and spoke to the school. There was this big thing, So we used to cruise down there heaps. Like for pregnancy testing … That was alright. It was good. – Olivia, Female, 26 years old

Using external facilitators could also help to circumvent the discomfort that some participants reported experiencing around teachers when discussing sex-related topics – ‘I don’t want to talk to teachers [about sex]’ – Violet, Female, 17 years old.

Other participants reported positive experiences with schoolteachers and described various characteristics of teachers they felt comfortable around and who made effective sex education facilitators.

It’s like the teachers that care about you learning but they’re not strict. Like they’re sort of easy teachers but they’re fair … They’re nice and you can talk to them about all that stuff [sex and relationships] ‘cause they’re not like them big, hard teachers’. – Julia, Female, 17 years old

Methods of delivering education were seen as important to determining student engagement. For instance, some participants thought it was important that education be delivered in more engaging, fun, and interactive ways – such as through discussion, games, activities, and creative media.

I think people are pretty engaged because I remember we had sex ed … You had to learn about it and … everyone thought it was funny because it was a bit awkward and funny. It was a good way to learn though. It was all about anonymity … Everyone got post-it notes and if they have a question about sexual health or anything to do with sex, they’d write it down and put it in a box … they get shuffled around and every note will be pulled out and answered. – Frank, Male, 18 years old

Some participants also emphasised the need for open and non-judgmental approaches. More specifically, several participants talked about sex education being delivered in ‘positive’ ways – which included talking about sex as something normal and healthy, promoting healthy behaviours by emphasising their benefits, and steering away from strategies that use fear or shame to discourage certain behaviours.

Like groups and classes on like what they need to learn but like, in a positive way. Not something that’s negative, that makes them feel scared or anything like that. – Kelly, Female, 19 years old

Sex and gender appropriateness

Participants’ responses varied when asked whether sex education in schools should be delivered separately to boys and girls. Some participants felt that sex education in schools was not culturally appropriate and should be delivered to different genders separately with regard to cultural understandings of men’s and women’s business in the Australian context:

They [sex educators] don’t realise that some things have gotta be separate for us [Aboriginal young people] … Like just because they took our traditional practices and traditional law away from us doesn’t mean that those cultural things don’t exist for us – you know, where there is men’s business and there are women’s business … And then they wonder why we don’t contribute, or we don’t listen to ya’s. – Olivia, Female, 26 years old

However, some other participants felt sex education did not need to be culturally specific, believing that sex and sexual health were universal experiences – ‘There’s no differences, it’s all the same really’ – Mia, Female, 17 years old. Moreover, some believed that sex education should be delivered with young men and young women together.

I think so they know about each other. Just so they know how to deal with the other person. Like their girlfriend. They know what’s happening so they’re not thinking ‘Ew’. Cause you know, like young boys think about the girls’ periods, they don’t understand it. But then older boys, because they know about it, they aren’t really disgusted, and they don’t embarrass other people cause of it. – Julia, Female, 17 years old

Aboriginal community-based education

Aboriginal community-based sexual health education and programmes may be an effective way of meeting the needs of young people whose needs are not being met by mainstream school-based sex education – such as when sex education programmes inadequately consider social and cultural differences for Aboriginal young people (as discussed above) or curriculum that overlooks the sex education needs of Lesbian Gay Bi-sexual Trans-gender, Queer and Intersex (LGBTQI+) students. These issues were raised by one participant, who described learning a lot about sex and relationships at a vacation camp for LGBTQI + youth:

I think that [young people] are in need of guidance, and I think that establishing groups – like at community centres for mob and community, as well as like queer groups – is insanely helpful. Like essentially all my sexual health knowledge I have explicitly gained through the fact that I’m queer and for some reason, it feels like queer people are all about sexual health … So when I went to gay camp [a camping trip for queer youth] when I was like 15, they hammered it. They had so many sexual health sessions. – Madelaine, Female, 20 years old

It was felt by participants that community-based services were often preferable and better equipped to support sexual health and deliver sex education in ways that considered the local community context and the specific needs of people accessing those services, such as that described by Scarlett:

I know we have [local Aboriginal Medical Service], and that has a variety of programs where a lot of Aboriginal people can go and participate, willingly, to be able to try and get some help. And it’s for free. Like they don’t have to pay because, you know, they might be tight with the money. And I know that in my community, for Aboriginal people, it’s a big help for everyone. Especially for teenage girls. My mum, for instance, she works with teenage girls who are pregnant, and she helps, she guides them into what’s right and what’s wrong and how to do this and how to do that. – Scarlett, Female, 17 years old

• 3. Intergenerational learning: family, Elders and peers

Many participants emphasised the important role that family members could play in informing Aboriginal young people’s knowledge and understandings of sex and relationships, such as the use of contraception, navigating consent, getting sexual health tests, dealing with relationship problems, and accessing health services (with family members often accompanying young people).

I think there’s always that one person in your family that will tell you. Like it could be your parents, could be your cousin, could be your aunt. Like they could give you advice … Me, personally, I’d go to my mum ‘cause she always wanted to have that talk with me. – Ava, Female, 16 years old

Participants saw lived experience and the knowledge that came from it as particularly valuable. Conversations with older relatives and other adults were therefore highly valued by participants as older people ‘had lived through it’ and thus offered first-hand wisdom.

I think your parents could be one of the best people to talk about it because they have a lot of experience, because they’re a lot older and how they did stuff, how they took care of their bodies. – Ellie, Female, 21 years old

Participants also emphasised the role of Elders in educating Aboriginal young people. Elders are highly respected (usually older) people in communities who hold knowledge and have esteemed roles in teaching and guiding community members. Although their teaching was more often about broader social and relationship issues than sex specifically. All the participants had a high regard for what Elders said.

If an Elder was to come and talk to me about something like that, I’m mature enough to understand what they’re saying and, you know, learn from my mistakes and learn from what they’re saying. – Luke, Male, 19 years old

Leadership from Elders was seen to encourage more open dialogue about sex, promote positive approaches to sexual health and minimise shame:

I really like going to conferences and different events where Elders and other older Aboriginal people kind of take charge. For example, some of our Elder women talk about domestic violence within the community. Like that stuff I respond to because I need to be made aware of these issues and obviously it’s relevant to me as an Aboriginal woman. – Madeleine, Female, 20 years old

Most participants described young people as most likely to talk about sex and relationships with their friends and peers, often because there was less fear of judgment and a higher sense of relatability. If participants were of the same gender and/or also Aboriginal, this could also enhance the sense of relatability and mutual understanding between people.

I think they do talk about it more with their friends. They’re not really embarrassed or uncomfortable like in a situation like with their family rather than their friends. And if their friends are all doing it then they feel more comfortable talking about it. – Lilly, Female, 16 years old

However, some participants were also conscious that information from friends and peers was not always reliable. It was therefore seen as beneficial for young people to use multiple sources of information, such as using the internet to verify information, seeking further advice from family, or going to a doctor for an expert opinion.

But sometimes our friends don’t know what they're talking about and then we might not know where to go for help from like a GP or a doctor. That's why we might go to our families. – Scarlett, Female, 17 years old

• 4. Choice and self-determination through a wide range of sexual health services

General practitioners and hospitals

Many participants saw general practitioners (GPs) or ‘the doctors’ as one of the first places young people would go if they had sexual health concerns. GPs were seen as possessing expert health knowledge and as being able to refer people to more relevant or specialist health services if necessary.

If I was concerned or something, I would go to my doctor first and talk about it, and then if they like recommended me somewhere, I’d just go there. – Damien, Male, 17 years old

Multiple participants described the benefit of having a ‘regular’ GP (sometimes one they had been seeing since childhood) as it could enhance rapport and because the GPs familiarity with a patient’s medical history and unique needs were seen to improve the quality of tailored care.

Me, personally, I would go to the doctor that I’ve grown up with ‘cause he knows all my medical history, knows all my problems and everything. So he would understand more. – Charlotte, Female, 17 years old

Aboriginal medical services and community services

Many participants preferred to access healthcare and sexual health support at an AMS. People preferred these services because they were seen as culturally appropriate and having a broader knowledge of Aboriginal health issues and needs (such as adult health checks, culturally specific mental health services), more Aboriginal staff, stronger connections to the local community and an increased sense of comfort and safety.

At an AMS, they see it from an Aboriginal perspective. They’re trained to see it from an Aboriginal perspective so yeah, it's just more suited to the needs of Aboriginal people. – Adam, Male, 18 years old

Participants talked about seeking sexual health support from Aboriginal community and health centres, especially for seeking advice, obtaining free contraception and being referred to other services. Many participants described positive relationships with local Aboriginal community and health service workers and gave multiple examples of Aboriginal young people receiving support from them.

I’m 99 per cent sure that, if you walked into the local community centre here and asked for condoms no matter what age you are, I know they’d give it to you. Only in the sense of like ‘it’s for your protection’. Like, ‘if you need them because that’s what you’re going to do, then go for it. – Ethan, Male, 17 years old

Sexual health services

Some participants thought sexual health clinics were ideal places to go for sexual health issues as they were seen as having more specialised knowledge, and accessing them is free of cost in Australia. Sexual health clinics were also identified as a place where young people could easily access free contraception.

The sexual health clinics are probably the most apt. If you’re going to go anywhere, that would be where you’d want to go, right? I feel medically on the sexual health side, you would be able to get a lot more guidance than you would from friends or even a [general] doctor because it is so specialised. – Susie, Female, 21 years old

There was also a sense that such services were more likely to adopt a non-judgmental and positive approach to sexual health, with some reporting positive relationships with sexual health clinic staff. This could decrease experiences of stigma (which were sometimes reported in general health settings) and foster an environment where people felt more comfortable discussing sex.

Well, [local sexual health clinic] was good. I remember it made all the difference. Like we were these little black kids rolling around for pregnancy tests. But I remember there was a woman in there and she was a white woman. But she got it. She was married to a black man as well, which helped. And had her own black kids and stuff like that. So she was always real nice and that. Like the workers, like that makes a difference massively. So us girls would only go to her and that’s it. – Olivia, Female, 26 years old

Sexual health support in youth service settings

Several participants identified youth health services, youth programmes and youth workers (who worked at health and community services) as being positive places for young people to go for healthcare and sexual wellbeing support.

When she was going to [local youth health service] for youth meetings, it was really beneficial, because, she felt like she could go somewhere after school and she could invite friends, and it wasn’t intense, it was just [casual]. It was just rocking up and just talking about different stuff really … I know young people engage with that kind of environment … that space is critical to learning about yourself – Susie, Female, 21 years old

Overall, participants named a variety of places to seek help for issues relating to sexual health and while GPs and AMS were most commonly cited, with the AMS recognised as the safest and most appropriate location, other services like specialised sexual health clinics were also mentioned.

Discussion

This research found that Aboriginal young people seek sexual health information and health services online. School-based sex education programmes had mixed reviews, with a preference for programmes delivered by external specialists through interactive ways with clear and accurate information about sex and relationships and where to go locally for STI testing, contraception and services. The content, facilitator and delivery methods were important in determining the level of engagement by Aboriginal young people with the information provided. Family, the broader community, and specialised medical services were trusted sources of information. AMSs were especially valued as they provided culturally appropriate services and sexual health clinics were seen as having specialised knowledge and low levels of judgement.

Aboriginal young people who participated in our study sought sexual and relationship information online as this was fast and anonymous but they also acknowledged that some information was not accurate or may promote unrealistic expectations. A study in Queensland, Australia, with Aboriginal young people similarly highlighted that participants were seeking accurate and timely sexual and reproductive health information (Hickey et al., 2021), and a review of Aboriginal young people’s social media and internet use highlighted that the Internet gave young people a sense of control (Rice et al., 2016). A study of migrant young people living in Western Sydney also found that they used the internet to access sex and relationships information as well as accessing information through sex education provided by the schools they attended (Botfield et al., 2018). Campaigns such as the Aboriginal Health and Medical Research Council of New South Wales’s ‘It’s Your Choice’ campaign, which focussed on educating Aboriginal young people to make informed sexual and reproductive health choices through sharing information and through activities on their Facebook page, may help to empower young people when using the internet and social media (Cairnduff, 2013).

Participants valued the lived experience and advice from peers, older relatives and Elders, reflecting the importance of intergenerational learning in Aboriginal communities. A study in southern Queensland of Aboriginal young people supports our findings (Hickey et al., 2021), noting the important role of aunties, uncles and Elders as knowledge holders. This can be further connected to Aboriginal ways of knowing and learning where knowledge can be passed down through generations through the sharing of stories and experiences (Martin & Mirraboopa, 2003). Another study in the Northern Territory, Australia highlighted the importance of peer support with Aboriginal young people feeling safer sharing sexual health information with friends and sometimes attending clinics together (Bell et al., 2020). As Aboriginal young people are seeking information from family and peers, it is important to promote positive messages about sex and relationships to reduce stigma and facilitate a more open dialogue. This also presents an opportunity to explore health strategies that adopt a ‘whole of community approach’ which can involve family, Elders, peers and the wider community, which better reflects the collectivist kinship of many Aboriginal communities and can provide the endorsement that young people need to engage in topics that may be perceived as taboo (D’Costa et al., 2020).

There were positive and negative views from the young people in our study about sex education programmes in schools. As other Australian studies have shown (Waling et al., 2021), young people want information that goes beyond the physiological basics and talking about STIs. They also want information which increases knowledge and skills relating to gaining sexual consent, building positive relationships and solving problems (including how to deal with a relationship break-up). More positive statements came from students who attended schools that used external sexual health educators to deliver sex education. A systematic review of young people’s views about school-based sex education programmes reported that schools had difficulty accepting that some young people were already sexually active, while young people felt vulnerable and that programmes were ‘out of touch with our lives’ (Pound et al., 2016). This review also highlighted young people’s reports that school-based sex education could be negative, gendered, heavily focussed on sex between a man and woman only, and that they disliked their teachers delivering sex education programmes due to a sense of blurred boundaries, lack of anonymity, and increased embarrassment with teachers often being poorly trained. This suggests that Australian schools might consider engaging external sex education specialists who can deliver the sessions, refer students to local services, and facilitate a confidential, safe and positive environment.

Our analysis shows that what is considered culturally appropriate, and gender-affirming, within sex education, varies in different communities and between individuals. This data suggests that Aboriginal young people have differing needs for sex education – while school-based education might address general concerns, Aboriginal community-led interventions or those aimed at LGBTQI + youth can be more specific and engaging. This suggests that choice is important: Aboriginal young people note that different services offer different approaches to sexual health (comfort and safety, positive and specialised, broader wellbeing support) and that offering a choice of various service locations and educational programmes can support self-determination in how Aboriginal young people manage their specific sexual health needs.

AMS and Aboriginal community centres were highly valued by our participants with one participant highlighting that staff were seen to provide culturally safe access to clinical and allied health services. Similarly, a study of 55 Aboriginal people showed that AMS were a trusted source of sexual health information and a safe place to access STI testing and reproductive health services (Hickey et al., 2021). Sexual health programmes that aim to increase STI testing have been trialled with a few AMS in NSW; with one sexual health quality improvement programme tripling chlamydia and gonorrhoea testing rates among Aboriginal young people over a three year period (Graham et al., 2015). The key to this sexual health programme was that the interventions were designed by AMS staff, community members and young Aboriginal health workers who knew the needs of local young people (Graham et al., 2015). The young people in our study also valued sexual health clinics as they perceived staff to have high levels of sexual health knowledge and low levels of judgement about sex-related matters. Incorporating cultural safety and awareness training for staff – as well as posters depicting Aboriginal and LGBTQI + people in waiting rooms – may help increase the attendance of Aboriginal young people at mainstream sexual health clinics.

Central to establishing cultural safety, as described above, is consultation and a strong understanding of the needs of the local community. As our data indicates, what is considered culturally appropriate with respect to school-based sex education can vary with some young people feeling separation of the genders was essential to meet cultural protocols, while others believed it was better to learn together. The need for culturally safe and appropriate sex education is widely recognised among health service providers, but what culturally safe and appropriate education looks like is not clear in the research literature (Sullivan et al., 2022). Research with Aboriginal LGBTQI + youth and health service providers found that providers felt unsure about how to work safely and effectively with Aboriginal LGBTQI + young people which led to a lack of response altogether. However, other mainstream sexual health clinic providers have worked effectively with Aboriginal communities and young people on matters of sexual health by using partnership and consultation as the central approach. For example, the Strong Family Programme involved sexual health experts working closely with Aboriginal communities and families, with long lead-in times for consultation and partnership to establish the specific needs and preferences of the community with regard to sexual health education (Duley et al., 2016). Here, genuine consultation is the key element that ensures that culturally appropriate and effective sex education is delivered.

Limitations

Our research makes an important contribution by taking a strengths-based approach and focussing on how Aboriginal young people build sexual health and drawing on participatory methods like peer interviewing. Aboriginal young people were recruited in Western Sydney, and the experiences of Aboriginal young people living in other areas of Australia may be different. We accept that some participants may not have discussed certain views about sex due to embarrassment, although the third-person peer-interviewing method was intended to reduce embarrassment. We acknowledge that the participants’ views may change over time as they gain more experience with sex and relationships.

Implications for policy and practice

Aboriginal young people value the information they receive about sex and relationships, with perhaps the most trusted source of information delivered through lived experience (intergenerational and intragenerational learning). Our findings suggest that Aboriginal young people seek similar information and skills from sex education as other non-Indigenous young people, such as more information about the needs of LGBTQI + young people, and more focus on the relational aspects of sex (e.g. consent, communication and healthy relationships). Our findings also suggest that a wide range of service access points (e.g. AMS, GPs, sexual health clinics, youth centres) is valued by Aboriginal young people, as they offered choice and self-determination in meeting their sexual health needs. Incorporating more culturally appropriate ways to offer services to Aboriginal young people in these mainstream settings would strengthen service responses for them. Finally, given the important role of intergenerational learning for Aboriginal young people, sexual health interventions could consider how to build parents’ and other adults’ skills in communicating with young people about sex and relationships so as to have a whole of community approach to sex education (Aggleton et al., 2010). We know of only one example of this approach in Western Australia (Government of Western Australia, 2015), however this strategy is from the perspective of Aboriginal parents and carers not Aboriginal young people themselves. It is an important resource given that intergenerational learning and collectivist kinship are aspects of Aboriginal and other Indigenous cultures internationally.

Conclusion

Aboriginal young people access the internet, health services and seek information through sex education and through their parents and elders to foster healthy sex lives, relationships and help them build confidence and control over their health. Aboriginal culture and identity are highly valued and seen as a strength that contributes to healthy well-being. School-based sex education programmes should be delivered by sexual health specialists, adopt a positive approach to sex, focus on building healthy sexual and romantic relationships, and follow an inclusive curriculum (such as providing information that is relevant to LGBTQI + young people). These results are focussed on meeting the needs of Aboriginal young people to improve their sexual wellbeing and support them build healthy relationships.

Acknowledgements

Seven of the twenty authors are Aboriginal people in Australia; including the first and third authors. The project is a partnership between UNSW Sydney, the Nepean Blue Mountains Local Health District, the South Western Sydney Local Health District and Family Planning NSW together with investigators from the University of Sydney, University of Melbourne, University of British Columbia and Charles Darwin University. The authors acknowledge the important contributions of Tamika Briggs, Kim Beadman and all the peer interviewers.

Disclosure statement

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

Additional information

Funding

The research was funded by Australian Research Council Linkage grant (grant number: LP170100190). The views expressed herein are those of the authors and are not necessarily those of the Australian Research Council. The Centre for Social Research in Health at UNSW Sydney receives support from the Australian Department of Health, and other external funders. National Health & Medical Research Council Investigator grants supported the salaries of authors Simon Graham (grant number: 2009727) and Michael Doyle (grant number: 1193618).