Introduction

Sexual and reproductive health (SRH) is a key component of quality of life [1] encompassing “physical, emotional, mental and social well-being” as well as “pleasurable, safe sexual experiences that are free from coercion, discrimination or violence” [2]. This includes the right to receive education and information about sexual health, the right to equality and non-discrimination, the right to decide the number and spacing of one’s children and the right to feel and express sexual desire [3, 4]. However, among a number of non-English-speaking migrantFootnote 1 and refugee populations who have resettled in the West, knowledge and uptake of preventative sexual health measures are poor, with SRH services being underutilised [5,6,7]. This can lead to negative SRH outcomes [8, 9].

Previous research has established that migrant and refugee women’s SRH can be negatively influenced by challenges experienced through migration or displacement [5, 10,11,12]. Prior to resettlement, there is often limited opportunity to learn about SRH due to poor access to health services and information [9]. Among women, low prioritisation is often placed on sexual health needs due to resettlement challenges [5, 11, 13], and limited knowledge of health resources and services in the host country [6, 10, 14] can result in poor SRH knowledge [7, 9, 15]. Further, SRH knowledge is mainly sourced from peers, the media, magazines and other informal sources [9, 16, 17], allowing incorrect knowledge and myths to perpetuate among community members [15, 18, 19].

While knowledge is a major determinant of SRH behaviour, socio-cultural factors also inform and shape knowledge, beliefs and practice [12, 15, 20, 21]. Cultural and religious norms can influence acquiring sexual health literacy and behaviours, and can contribute to lack of knowledge and access to SRH services [18, 22]. Among migrant and refugee communities, talking about sex is often forbidden due to cultural and religious taboos [18, 23, 24]. Sexual health services may be seen as culturally inappropriate, thus avoided, particularly within cultures that emphasise the importance of pre-marital virginity [25,26,27]. Further, patriarchal values and culturally prescribed gender roles may impact on women’s access to family planning services and sexual health screening [7, 28], with some married women fearful that if they demand safe sex their husbands may divorce them [29]. Cultural constructions about the aetiology and treatment of illness may also act as barriers to utilising SRH services [8, 14, 30]. For example, beliefs around conception and the causation of cervical cancer led some women in African communities to resist using contraception [15] and in Latina communities to avoid cervical screening [31].

Inadequate SRH knowledge combined with low use of sexual health services can have serious negative health consequences for migrant and refugee women [7, 9, 14]. For example, engagement in risky sexual behaviours may result from seeking knowledge from unreliable sources [13, 16, 17]. Delayed sexual health screening may result in late diagnosis and treatment of cervical cancers [31, 32] or sexually transmissible infections [33, 34]. Inadequate contraception knowledge and use may lead to unwanted pregnancy and abortion [19, 21, 35]. Inadequate knowledge about sexual satisfaction or sexual pain may have negative implications for women’s psycho-sexual well-being and quality of life [7].

There is a need for health providers to understand socio-cultural barriers to SRH in order to provide comprehensive healthcare for all migrant and refugee women [24, 36, 37]. Previous research has tended to focus on specific cultural groups, for example the Vietnamese or South-East Asian populations in Australia [30, 38], which results in the marginalisation or invisibility of health experiences and needs in other migrant groups [38]. SRH research has predominantly examined pregnancy, childbirth and post-partum experiences [39, 40], meaning that experiences of sex, sexuality and sexual health practices have largely been overlooked [17, 28, 38]. Research that has been conducted on migrant women’s sexual health has primarily focused on unmarried women, from single cultural groups [20, 28, 32, 41]. SRH experiences and needs are also likely to differ for migrant and refugee women depending on their type of resettlement, such as humanitarian or professional migration [12, 42]. In order to identify unmet sexual health needs and specific cultural barriers to accessing sexual health services, there is a need for qualitative studies that provide in-depth analyses of the constructions and experiences of SRH among married and unmarried migrant and refugee women, from a range of cultures and backgrounds, across the reproductive lifecycle [43,44,45].

Identifying how SRH is constructed and experienced by migrant and refugee women is essential in order to provide culturally safe medical care, sexual health education and health promotion and to increase capacity for all women in accessing SRH services [46,47,48]. The aim of the present study was to examine constructions and experiences of SRH in recent migrant and refugee populations in Sydney, Australia, and Vancouver, Canada, across a range of cultural and religious backgrounds. The research question was: how do migrant and refugee women’s constructions and experiences of SRH influence SRH behaviour?

Method

Participants and Recruitment

A total of 169 migrant and refugee women took part in the study, as part of a larger research project examining the SRH of migrant and refugee women living in Australia and Canada [49]. Participants were 18 years and over and had settled in Australia or Canada in the last 10 years from Afghanistan, Iraq, Somalia and Sudan. Sri-Lankan (Tamil), Indian (Punjabi) and South Sudanese women were included in the Australian sample and women from South America (Latina) in the Canadian sample. Participants ranged from 18 to 70 years old, with a mean age of 35 and with an average length of time since migration of 6.3 years. Participants practised a range of religions, predominantly Islam, Christianity and Hinduism. The majority of women had migrated as humanitarian refugees, and only one participant (Latina) reported as being in a same-sex relationship. Table 1 provides the demographic information by cultural background for all participants.

Table 1 Demographics for participant interviews and focus groups by cultural background
Full size table

Australia and Canada were chosen as the research sites due to being similar geographically and having comparable migrant populations. The countries of origin and cultural backgrounds of the participants were chosen through consultation with stakeholders who support or provide sexual and reproductive healthcare to non-English-speaking migrant and refugee communities. The cultural groups selected for this study were recognised as being underrepresented in previous research, with women underutilising current SRH services, despite reflecting a significant percentage of recent migrant population in Australia and Canada. Women were recruited to participate through community support workers and pre-existing community groups, as well as through snowballing and the use of flyers. Participants provided informed consent to take part in interviews and focus groups involving discussion of SRH. Any queries about participation were addressed with a community worker in the first language of the participant to ensure understanding. The research was approved by Western Sydney University Human Research Ethics Committee and ethics committees of the project partners. Data were collected from July 2014 to March 2016.

Procedure

To enable the collection of in-depth stories of migrant and refugee women’s constructions and experiences of SRH, a qualitative approach was used [50]. There were 84 one-to-one interviews and 16 focus groups composed of 85 participants conducted. The majority of these interviews (73%, n = 124) were conducted in the first language of the participants by community interviewers who received training by the research team prior to commencing data collection. Individual feedback was provided to the interviewers after their first interview, and support was given throughout the data collection process of interviewing, translating and transcribing. Two members of the research team conducted the remaining interviews and focus groups with women who preferred to speak English or to be interviewed by a non-community member. To enhance data richness, one-to-one interviews were used to elicit personal accounts that women may not have been willing to disclose in a group setting due to the culturally sensitive topic, while focus groups gathered insights into socio-cultural norms through group discussion [51, 52]. The groups were homogenous, consisting of women from the same cultural background, and divided by marital status and age where possible [53]. Among the recruitment sample, there were very few cases of participants seemingly fearing a lack of confidentiality; one participant (interviewed by a community interviewer) revoked consent and another (interviewed in English by a non-community interviewer) refused to be recorded.

Interviews and focus groups took place at venues preferred by participants and lasted an average of 90 minutes. The interview and focus group schedule focussed on the reproductive lifecycle, sexuality and SRH, including open-ended questions exploring migrant and refugee women’s constructions and experiences of menarche, menstruation and menopause; fertility and contraception; sexuality; sexual health and sexuality education; and health practices and information seeking. Women gave current accounts of their constructions and experiences of SRH as well as retrospectively describing past experiences and behaviours. Recruitment within cultural groups continued until data saturation was achieved.

Analysis

A social constructivist epistemology informed our research design, where meaning is socially and culturally produced [54]. Thematic analysis, a qualitative method for identifying, reporting and interpreting patterns or themes within interviews, was used to analyse the data [55]. Community interviewers transcribed and translated audio-recordings of interviews that were conducted in the participants’ first language while those conducted in English were professionally transcribed verbatim. Two members of the research team read through a subset of the interview transcripts independently to identify first-order codes such as “menstrual learning”, “talking about sex” and “screening behaviours”. The coding process involved discussion and decision-making to create more distinct codes. The data set was coded using NVivo, a software program that helps organise coded data, with continual refinement during the coding process to help elicit and identify themes. The coded data were organised and presented using a conceptually clustered matrix [50, 56]. This enabled the visual display of patterns within and between the different cultural groups by using exemplar quotations provided in tables to illustrate each of the themes. Quotations presented in this article are substantiated by use of pseudonym, cultural background and age. No distinction is made in reference to country of residence as analysis revealed no significant difference between accounts of participants from Australia and Canada.

The research team consisted of academic researchers and community migrant workers from different ethnicities. The community interviewers were migrant women who worked within their communities and spoke the language of the participants. Throughout the research process, we engaged in reflexivity, aware that our own experiences and socio-cultural backgrounds shaped our research findings [57]. In this article, we present key themes across the cultural groups. The key themes identified were “Women’s assessments of inadequate knowledge of SRH and preventative screening practices”, “Barriers to SRH” and “Negative SRH outcomes”.

Results

Women’s Assessments of Inadequate Knowledge of Sexual and Reproductive Health and Preventative Screening Practices

Across all cultural groups, participants described themselves as having a lack of knowledge about SRH (Table 2). Absence of knowledge of menstruation prior to menarche was commonly acknowledged, and many women had not learnt about the function of menstruation until they were pregnant with their first child. Many participants also described having inadequate knowledge of menopause, often positioning it in a negative way as an illness. Sexual knowledge prior to marriage was frequently acknowledged to have only been learnt through books, film and peers. Many women recognised that they had inadequate knowledge about contraception, cervical screening practices and human papillomavirus (HPV) vaccination. Some women demonstrated incorrect knowledge; for example, several Somali women were under the misconception that the HPV vaccine caused cancer. Participants also reported inadequate knowledge of sexually transmissible infections, with knowledge limited mainly to having heard about HIV/AIDS.

Table 2 Women’s assessments of inadequate knowledge of sexual and reproductive health
Full size table

Barriers to Sexual and Reproductive Health

A number of cultural and relational barriers to obtaining knowledge and access to SRH were identified (Table 3). Menstruation was positioned as shameful and a forbidden topic, with little discussion taking place between mother and daughter or between peers. For many participants, talking about sex as an unmarried or married woman was not permitted. Even thinking about sex before marriage was considered as “harming your religion” (Ara, Afghani, age 34), as culture and religion dictated remaining virginal until marriage. Women who engaged in premarital sex were no longer seen as desirable marriage partners and could experience familial and social exclusion. Cervical screening and the HPV vaccination were seen as a threat to the virginity imperative, thus not supported practices for unmarried women. Some participants stated that their religion or culture forbade them to use contraception.

Table 3 Barriers to sexual and reproductive health
Full size table

Across all cultural groups, there were cultural and relational pressures on women to reproduce and a preference for a male child. More specifically, it was expected that Somali, Sudanese and South Sudanese women bear many children. For most participants, contraception use was negotiated with husbands and in some cases with parents and in-laws, with family planning taken into consideration only after the first child was born. Due to patriarchal and cultural values, some participants reported that they felt unable to refuse marital sex or to address sexual pain and discomfort. Some women also felt unable to ask their husbands to be tested for sexually transmissible infections (STIs), and prioritised their family’s health over their own, particularly for participants who had many children.

Negative Sexual and Reproductive Health Outcomes

There were a number of negative health implications for women with inadequate SRH knowledge or whose knowledge was shaped by cultural barriers (Table 4). Many participants gave accounts of inadequate menstrual knowledge and communication and bleeding that was concealed and kept secret. Consequently, women’s experiences of menarche were described as frightening or shocking, and participants rarely spoke to health professionals about premenstrual or menstrual difficulties. Due to limited premarital sexual knowledge, participants disclosed feelings of anxiety on their wedding night, describing the experience of first sexual intercourse as scary and painful. Many married women considered the focus of sex to be male pleasure or reproduction. Experiences of painful sex were common, yet many women had little knowledge and use of lubricants to ease vaginal discomfort. These women also often felt unable to discuss painful sex or sexual consent with their partners.

Table 4 Sexual and reproductive health outcomes
Full size table

Many participants had worries and misconceptions about contraception use that they attributed to inadequate contraception knowledge. Some participants gave accounts of inadequate family planning, associated with unplanned pregnancies and abortions. Sexual health screening practices were deemed inappropriate for unmarried women, who were forbidden to be sexually active. Addressing sexual issues with a doctor was often seen as shameful or embarrassing, with exposing the body a major factor in delayed healthcare-seeking.

Discussion

Among the majority of women in our study, irrespective of cultural background, there was evidence of reports of inadequate SRH knowledge. A major barrier to sexual health literacy was socio-cultural norms that prohibit open discussion about SRH, as reported previously [17, 18, 20, 21]. Not being able to openly talk about the menstrual body, sex and sexuality impacted upon women’s SRH and their health-seeking practices [9, 12, 41]. Among our participants, inadequate knowledge and silence around menstruation were associated with reports of traumatic experiences of menarche [58,59,60]. However, some women, post-migration, were eager for support in educating their daughters in preparation for menarche. This is consistent with previous research findings where women who had themselves received inadequate menstrual education and support wanted to spare their daughters from traumatic experiences at menarche [59,60,61]. This highlights a need for service providers to facilitate ongoing menstrual health education and support for young girls and their mothers.

For many participants, whether unmarried or married, talking about sex was viewed as disrespectful and culturally inappropriate, as reported in previous research [7, 18, 23, 24]. Due to this taboo, many of our participants disclosed feelings of anxiety on their wedding night and traumatic first sexual experiences, due to their lack of sexual knowledge [7]. Silence around sex can also mean that sexual health concerns are less likely to be addressed with partners, family members and health providers [62]. Some participants requested information on how to talk to their adolescent children about sex, indicating a need for culturally appropriate sexuality education to support families in communicating about sex [63]. However, a premarital virginity imperative occurred across all cultural groups in our study, with SRH services seen as culturally inappropriate and unnecessary for unmarried women. Parental and community attitudes influenced and prevented access to cervical screening and the HPV vaccine, consistent with findings in previous research [18, 21, 31, 32]. Unmarried women may be ashamed to buy contraceptives [45] and be fearful of parents or the community finding out [15], with personal reputation and family honour jeopardised if it is known they are engaging in premarital sex [7, 8, 17]. In addition, intergenerational differences in attitudes and beliefs around sexuality, post-migration, have been found to create family conflict [64]. Women’s sexual health is at risk by not being able to freely access sexual health screening clinics, resulting in women being ill equipped to articulate their sexual rights [65]. This includes having little knowledge of, or access to, contraception and risk of social exclusion if sex (whether consensual or not) or pregnancy occurs outside of marriage [7]. Cultural prevention of access to sexual health information can also result in women resorting to informal sources of information, risking the transmission of incorrect knowledge [15, 19]. There is a need, therefore, for service providers working with non-English-speaking migrants and refugees to encourage and support families to use culturally safe approaches to sexual health, including provision of information on sexual health screening and contraception [21], and to provide SRH education in ways that help address intergenerational conflict [64].

SRH is often a low priority, particularly for newly arrived migrant and refugee women who prioritise family commitments and resettlement concerns ahead of their own needs [11, 13, 66]. A delay in healthcare seeking for SRH concerns was common among our participants. Culturally prescribed gender roles, combined with patriarchal values, may influence women’s ability to have control over their sexual and reproductive needs [7, 43]. Some married participants, for example, faced family pressure not to use contraception, and were thus unable to control the number of children that they had, due to the cultural importance placed on having children. This demonstrates that contraception knowledge does not necessarily translate into contraception use [67]. Some participants felt unable to refuse marital sex, and endured unwanted or painful sex as they saw it as not their “right” to refuse consent. Likewise, women said that they would be powerless to persuade their husbands to agree to STI testing, even when there might be suspicions of extramarital sex. These culturally gendered restrictions mean that women may have little sexual agency and autonomy, and are at risk of unplanned or unwanted pregnancies, STIs and sexual pain. Thus it is important for healthcare providers to be aware of the cultural and social sensitivities that migrant and refugee women have in regard to SRH. There is also a need for engaging with migrant communities. For example, the use of peer educators and navigators [6, 68] creates a bridge between communities and the health system, and embedding SRH education in culturally acceptable programs, in consultation with community and religious leaders, is a way of receiving community support on SRH issues [49, 69].

Despite cultural and religious taboos around SRH, many participants within the safe space of the interview and focus group setting showed an interest in receiving information on a range of topics including cervical screening, HPV vaccination, sexually transmissible infections, contraception, painful sex, negotiating sex within their marital relationships, preparing daughters for menarche, menopause and sexuality education. Some women, particularly Sudanese participants, were keen for their husbands to receive sexual health education, which has implications for future research in considering men’s perspectives on SRH and for SRH resources to be developed for migrant and refugee men. Participants indicated preferences for a variety of resource delivery options such as groups and one-on-one talks, as well as reading and visual (including web-based) material, highlighting the need for developing resources in a range of modalities, including material in community languages as well as for women with low literacy levels [21]. An important consideration is appropriate timing for disseminating SRH information, for example, providing cervical screening information at antenatal classes and following childbirth while women are engaged with healthcare providers or talking about lubricants at cervical screening examinations [49]. A strong preference for female practitioners has implications for practice, in providing female healthcare providers and accessible women’s health clinics.

There are a number of strengths and limitations to this study. Strengths include interviewing women from different cultural backgrounds, which made comparisons between cultures possible. Being able to interview participants in their first language allowed women who were not fluent in English to participate, as they were not constrained by language issues. The community interviewers were able to explain terms such as menstruation, menopause, contraception, cervical screening and sexual identity labels in language that the participants understood. Providing participants who were able to speak English with the option of being interviewed either in their first language or in English meant that we were able to give women the option that they felt most comfortable with. Having these flexible options was important considering the sensitive nature of the interview questions and in being able to demonstrate cultural sensitivity. We spent a considerable amount of time building rapport and establishing a strong working relationship with community interviewers and the community, and allowed ample time for translation of interviews, along with flexibility in choice of interviewer—important for future research using community interviewers. In collaboration with community stakeholders and SRH service providers, we have reflected on the research findings and produced recommendations for healthcare practice [70], a further strength in the research. Limitations include the fact that researchers could not back-check translated transcripts for accuracy, women often retrospectively reflected on their experiences, and given the small subset of women from each cultural background, experiences of SRH may not be representative of their community as a whole. There were also differences in interviewing skill and comfort regarding discussion of sexuality across the community interviewers. Future research should ideally use community interviewers who have more substantive training in qualitative methods or who are experienced in discussing sexual issues.

In conclusion, this research has demonstrated that migrant and refugee women are at risk of experiencing unmet SRH needs and negative health outcomes due to socio-cultural norms that contribute to the potential for inadequate SRH knowledge and low uptake of sexual health services. This highlights the need for healthcare providers in consultation with communities to develop culturally appropriate sexual health promotion initiatives [71] and approaches that are tailored for specific cultures [47, 72] that are accessible to all migrant and refugee women at resettlement irrespective of their socio-cultural background or category of migration [9]. SRH information needs to be provided in a range of modalities to meet women’s diverse needs [70]. To improve sexual health outcomes and increase utilisation of SRH services for migrant and refugee women, the focus needs to be not only on health education and increasing knowledge, but on understanding the socio-cultural constraints that may impede SRH knowledge and behaviour [3, 43]. This suggests that migrant and refugee women and their SRH needs should be treated holistically, focussing on the whole person within their socio-cultural context [73].