By Sarosh Naqvi
The subject of comprehensive sexual health education and care, specifically for refugees and migrants, is often overlooked. Some of the specific topics that fall under the domain of sexual health education and care are contraception, sex, pregnancy, and preventive health screenings (e.g., PAP smears and cancer screenings). Given the highly moralized nature of sexual health, however, some healthcare workers may fail to introduce and/or to adequately address the topic. Additionally, from many cultural perspectives, the subject of sexual health can carry significant stigma with it and/or it may be regarded as taboo.
Sexual health is an important aspect of one’s overall health. If patients do not have the opportunity to receive sexual health education and care, then it may lead to, for example, unplanned pregnancies and undetected sexually transmitted infections (STIs). It is often the case that migrants and refugees report never having received sexual health education in their home countries because it was considered taboo. This has resulted in a number of unfortunate consequences. For instance, according to one study, young girls from various countries (including Sudan, Somalia, and Iraq), were not educated about what a period was until their first menstrual cycle.
In 2017, Metusela et al. found that refugee and migrant women are at risk of having poor sexual and reproductive health outcomes (e.g. STIs, unplanned pregnancies) because they do not use available services. The study found three reasons that sexual health services are not accessed by this population: 1) minimal knowledge of healthy sexual and reproductive practices and preventive health screenings; 2) physical, geographical, and/or psychological barriers to receiving care; and 3) negative sexual and reproductive health results.1 Negative sexual and reproductive health results can be, for instance, being too anxious to address concerns with healthcare workers, unwanted pregnancies leading to terminations, engaging in risky sexual behaviours because of a lack of sexual health education, and/or avoiding contraception or delaying screenings because of incorrect information. Furthermore, financial and language barriers may influence whether sexual healthcare is sought, especially since Canadian government assistance for refugees and migrants expires after one year, which means that refugees have to pay for services themselves afterwards.
It is incumbent upon healthcare workers to provide thorough sexual health care and education for migrants and refugees. Sexual health education and care should be approached in the same way that other bodily ailments are addressed: as a normal part of a person’s life. It may be assumed that refugees or migrants who do not explicitly bring up a sexual health ailment or question do not have concerns, though this may not be the case. In addition to the fact that sexual health may be a particularly stigmatized topic in their country of origin, PTSD from traumatic past experiences may also inhibit patients from bringing up sexual health problems, especially in cases where patients may have been abused by aid workers and/or other trusted individuals.
From an ethics perspective, healthcare providers have a duty to ensure that they are providing benefit to patients and preventing undue harm. Additionally, developing trusting relationships has been shown to influence patient health outcomes. It often takes patients multiple visits in order to feel safe enough to confide in their healthcare provider(s); this needs to be considered when assessing a patient. As such, and insofar some refugees and migrants may be unlikely to broach the topic of sexual health, then healthcare providers may need to take additional time to build trusting relationships and to introduce the topic in a safe and comfortable way. Although healthcare providers have a duty to support each of their patients, taking additional time when working with refugees and migrants in particular may be justified from an equity perspective, particularly given the increased need to build trust and take responsibility for introducing taboo topics.
In one recent study, refugees who had lived in Canada for six to nine months participated in focus groups concerning the healthcare that they received. The participants expressed concerns about healthcare providers being dismissive of their ailments and/or slow in providing referrals or prescriptions. These concerns were particularly relevant to women and patients of colour. While there are likely systemic changes that need to occur in order to fully respond to these challenges, it is important that healthcare providers respond to the concerns of patients in a way that fully takes into account their expressed concerns, especially given their lack of familiarity with our healthcare system and the fact that they may be unable to advocate for themselves based on the norms from their country of origin.
Trust-building between migrants and healthcare workers can also be approached by hosting community focus groups. These focus groups can be facilitated by healthcare workers who speak the language of their patients or by enlisting the help of an interpreter. Here, valuable information on where to find resources about various topics can be provided, and sexual and reproductive health education sessions can be offered. Clear and repetitive messaging that addresses the stigma of sexual health needs to be at the forefront of these sessions, making sure that patients are aware that they can speak about their problems without judgement.
In short, sexual health education and care for refugees and migrants in Canada needs to be improved. Sexual health can ultimately influence a person’s overall health and well-being, but significant stigma about the topic may prevent refugees and migrants from bringing forward questions and concerns. Consequently, it is important that healthcare providers introduce the topic to refugee and migrant patients in a safe and comfortable way. In order to create a safe space for these patients to express any sexual health concerns, trust needs to be built. Trust-building between healthcare workers and patients can occur by spending more time with patients, enlisting the help of an interpreter, and/or by hosting community focus groups. Ultimately, comprehensive sexual health can be achieved for all refugees and migrants by implementing equitable approaches to care.
Sarosh Naqvi, MSc, is a recent graduate from the London School of Hygiene and Tropical Medicine where she studied Reproductive and Sexual Health Research in Public Health.