International students’ views on sexual health: a qualitative study at an Australian university

Additional keywords: consent, general practitioners, interviews, university health services, wellbeing.

The number of international students in Australia is rapidly increasing. In 2018, there were 693 750 full-fee paying international students in Australia, 10.1% more than in 2017.¹ International students contributed A$35.2 billion to the Australian economy in 2018.²

Corollary to the rapid increase in numbers of international students in Australia comes concern for their health and wellbeing. The provision of adequate, gender-specific sexual health education and services to international students comprises part of their human right to health.^3,4 Concerns, however, have been raised with regard to the wellbeing of international students in Australia. Recent news articles have asserted a lack of reasonable care taken by the government to ensure international students are well equipped for living in Australia, with specific concerns raised for their sexual health.^5–7

There is limited literature specifically relating to the sexual health of international students, so it is helpful to look at studies regarding the general health of international students. A survey at an Australian university found that one-third of international students described their health as being only ‘fair’, while one-fifth believed their health was having strong adverse effects on their studies.⁸ International students at the University of Tasmania have reported significantly lower levels of support than domestic students.⁹ Stakeholders have identified that international students may be particularly vulnerable when it comes to accessing sexual health care.¹⁰ Specific barriers, which are further discussed below, include sexual risk-taking, sociocultural and religious factors, cost and poor sexual health knowledge.

A survey conducted at a British university found that international students were engaging in higher risk sexual behaviour than domestic students.¹¹ There is scant evidence in the literature on this issue; nevertheless, Poljski et al. deem it likely that international students have a ‘high rate of unsafe sex practices’³. Furthermore, international students may be engaging in new sexual activity since arriving in Australia; Rosenthal et al. found that 12.1% of international students who were not sexually active at home became sexually active in Australia.⁸

A lack of adequate sex education and poor sexual health literacy may create significant barriers to accessing sexual health. One conference paper suggested that unfamiliarity with the Australian healthcare system negatively affects international students’ access to medical care.¹² Language barriers may also be an impediment; although international students are required to have evidence of English-language skills,¹³ a recent report on international students noted that ‘lack of English proficiency… [creates] a knowledge gap, such as comprehension of sexual health’¹⁰. Overseas-born university students have poorer knowledge of sexual health than their domestic peers, particularly regarding sexually transmissible infections (STIs) and human immunodeficiency virus (HIV);¹⁴ furthermore, a recent study at a Tasmanian university identified low rates of sexual health literacy among overseas-born students.¹⁵ Some studies have demonstrated that international students have communicated a desire for sex education.^16,17 Additionally, Baek et al. found that international students reported a perceived lack of access to health services and information on sexual health.¹⁸ These studies all reflect a lack of sex education among international students in Australia, and most suggest that this may be affecting sexual health.

Cost to the student has frequently been identified as a factor that may adversely affect sexual health. The compulsory Australian Overseas Student Health Cover may complicate the issue, with complex terms and conditions varying among insurance companies. Two American studies have found that international students lack knowledge regarding insurance coverage,^19,20 although there are no Australian data. Nevertheless, it is likely that complex insurance creates challenges for students accessing health care. In addition, international students who want to access HIV pre-exposure prophylaxis (PrEP) are obliged either to join a clinical trial or to import PrEP from overseas, a complex process that has upfront costs.^21,22 A recent Melbourne study found that although rates of HIV are declining in men who have sex with men (MSM), the incidence of HIV in newly arrived Asian-born MSM remains high, despite fewer sexual partners than their local peers.²³

There is limited research on the experiences of international students in Australia relating to consent and sexual misconduct. However, a large survey of students across Australian universities indicated that, although domestic students were more likely to have been sexually harassed or sexually assaulted at university than international students, some international students were unsure whether behaviours such as being kissed on the mouth by supervisors constituted sexual harassment or normal Australian culture.²⁴ This suggests that data in this report may be skewed by a lack of understanding of sexual harassment and sexual assault. Additionally, international students were more likely than domestic students to say that they felt embarrassed or ashamed following sexual harassment or sexual assault, that they did not know to whom to make a report, and some were concerned that reporting might affect their visa status.²⁴

Clearly, multiple areas may be affecting the sexual health of international students; however, there is little information regarding international student perceptions of sexual risk-taking, cost, consent and specific educational gaps. Hence, there exists scope for a qualitative study of such a complex topic as sexual health among international students. This study aimed to explore international students’ views and experiences of sexual health and wellbeing, in order to inform and update university policies and practices around sexual health care for this cohort.

This was a qualitative research project at one Australian university, to explore the views and experiences of international students with regard to sexual health and wellbeing.

Recruitment was restricted to students aged over 18 years, enrolled as an undergraduate or postgraduate international student at a selected Australian university. Students of all genders and university degrees were eligible.

A variety of recruitment strategies were used throughout May to August 2019. Electronic flyers were placed in Facebook groups, including the university Discussion Group, Medicine Noticeboard, Queer Collective and International Student Collective. Snowball sampling was also utilised. Later in the recruitment process, the research team employed purposive sampling by asking specifically for male and queer-identifying international students, in order to achieve greater variety in the participant group.

Participants were asked to contact the student researcher via email for one-on-one interviews. This study was approved by the University of New South Wales Human Research Ethics Committee (approval no. HC 190031). No participants withdrew from the study and no repeat interviews were conducted.

Data were collected through semi-structured interviews, conducted from May to August 2019 by the first author, a female student researcher. The student researcher informed the interviewees that they were an undergraduate university student with no prior qualifications, conducting this study as part of a research project for their medical degree. No one else was present at the interviews. Interviews took place on university campus, in a private library room. Formal compensation was not offered. Participants provided written informed consent before being interviewed.

Brief demographic information was collected at the start of the interview, and participants selected a pseudonym for use in reporting results. The interviewer asked participants about their views on sexual health, experiences and issues with sexual health, observations of their fellow students and potential avenues for change (Appendix 1). Each interview varied depending on the interests and experiences of the interviewee. All interviews were conducted in English and were audio recorded and transcribed verbatim. No new codes were generated in the final three interviews, indicating that data saturation was likely achieved.

The interviews were thematically analysed by the first author using the method described by Braun and Clarke.²⁵ This approach is both rigorous and flexible, making it appropriate for exploring individual experiences and the factors and processes that underpin and shape experiences. Interviews were coded inductively from the data, as well as based on domains identified before interviews. Data collection and analysis was conducted iteratively; these were refined during weekly meetings with the research team.

Initial codes were stratified into four final themes, based on prevalence of codes, discussion with the research team and our understanding of themes that were emphasised by participants. Themes were discussed and reflected upon by the research team.

Individual interviews were conducted with 13 international students at an Australian university. The interviews varied from 16 to 28 min in length. Basic demographic information for the students is included in Table 1. Pseudonyms selected by participants are used throughout.

Table 1.  Participant demographic details
International students at Australian universities are most commonly from South-east Asia.²⁸ Hence, two countries were modified to more general geographic identifiers (Europe and the Middle East), with the aim of protecting the anonymity of those participants

Four main themes were generated from the data: (1) consent and sexual misconduct; (2) cultural and familial taboos and evolving ideas since moving to Australia; (3) the paradox of information access; and (4) ideas about future support and education.

When asked to define sexual health, several participants brought up sexual consent without prompting. Almost all participants had a detailed concept of consent, although many felt that this was not necessarily embraced in their home country.

‘You don’t discuss consent in [home country]. You get married if you’re told to. So it’s very different in that regard.’ (Anya)

Several interviewees explained that their experiences of a more nuanced Australian view of consent had altered their views on sexual health.

‘I feel like definitely being in Australia has helped me to communicate [my expectations and boundaries] a lot better… just being in an environment where it’s a… more commonly discussed area, I’m able to naturally gain that knowledge.’ (Angela)

Notably, some participants described a dichotomy between having a clear understanding of consent and actually acting on that understanding in complex situations.

‘It’s easy for me to sit here and just go ‘yeah, you should just say no’… And then in a situation it’s actually much harder.’ (Gamora)

Some participants described concerns regarding the reporting of sexual misconduct and assault. There was a common perception that reporting might lead to unwanted attention on the reporter.

‘Victim blaming is such a big issue. And I think it still happens in cultures, like Asian cultures, where if you report something, if word gets back to your family, you might get blamed for it, even though you didn’t do anything.’ (Rachel)

In addition, a few participants misunderstood the role of police in cases of sexual misconduct and assault. One participant described fears that reporting to police might affect visa status:

‘And I think a lot of international students are worried that if they get involved in police stuff, that their visa’s going to be taken away, that they’re not going to be able to study here… and it’s going to go on their record. So a lot of people just choose not to make a big deal out of it.’ (Rachel)

Many participants described a shift in mindset that had occurred since moving to Australia. This was often coupled with an observation that sex and sexual health were culturally taboo within the participants’ families and cultures.

‘I come from… a very conservative Muslim country. And that has an effect, like my country, they have a certain view on sex. And here, they’re definitely much more open about it.’ (Rose)

Several participants indicated that sex, sexuality and sexual health were rarely or never discussed within the family home:

‘It’s not something that my family would discuss… my family is quite conservative… it was definitely on the internet. Sometimes when you click something, and something inappropriate just pop[s] out, and that’s how I started learning about it.’ (Sheng)

Participants often stated that when sexual health was discussed in families, it was explored in a superficial way, with little discussion around safe sexual behaviour. Some participants believed their parents took the approach of attempting to deter them from having sex before marriage:

‘I was maybe 12 or 14… and my mum would come into my bedroom, like ‘sex hurts so much, when I was with your dad, it was so painful’, and I just remember ‘just save yourself before marriage’.’ (Angela)

Many participants found Australia to be a more open, sexually permissive place than their home countries:

‘Australia is different; you don’t have as many restrictions.’ (Anya)

Often, participants explained that this transition from conservative cultural attitudes towards a more sexually permissive Australian culture was having an effect on their own experiences and behaviours.

‘Initially I was like, ‘Okay, I’ll find the one, and he’s going to be the only guy that I have sex with’. And then, lo and behold, started meeting friends who practice casual safe sex… like why not, what’s the big deal behind sex?’ (Shaniqua)

The paradox of information access is that participants have access to large quantities of information, but do not always feel capable of navigating available supports. Many participants felt that upon arriving in Australia, they had been bombarded with an overwhelming quantity of information by the university.

‘Every email that the university send[s] me [is] very useful, but I just don’t have time to go through all of them.’ (Sheng)

Sometimes, participants found this information inherently confronting. One participant described the surprisingly challenging experience of receiving a condom from a university society:

‘When I first got to Australia, [society] gave that goody bag, with the condom in it, that was huge – that was huge! Yeah, that could have been handled differently, just to be more sensitive to the difference in culture.’ (Shaniqua)

In the same way, many participants found it difficult to navigate the university’s support networks. Many described knowing there was relevant support out there, but not having the skills to navigate the system and access that support.

‘I’m not saying that there isn’t support, it’s just hard to know where to find it.’ (Angela)

‘I know there are numbers, but I’m not sure who I’d actually have to call.’ (Rachel)

Participants largely reported that they would be comfortable accessing general practitioners (GPs) in response to health needs; however, there was an overall lack of understanding of preventative sexual health and holistic support by GPs. Many participants explained that they would see a GP in response to a health problem, rather than for regular check-ups.

‘If it’s definitely something about health issue, I would go to the GP. But if it’s not something I’m worried about, I’d go to the internet.’ (Sheng)

Notably, no participants identified cost as a major issue. All participants were covered by the compulsory Overseas Student Health Cover, and although most participants had little knowledge about their insurance coverage, none stated that insurance limitations might dissuade them from accessing health services. One participant did, however, note that PrEP is difficult and often expensive for international students to access:

‘One thing that was a bit weird was that PrEP isn’t covered by our insurance.’ (Bob)

In addition, some students described embarrassment as being a negative feature of their visits or potential visits to GPs. However, none of these students ultimately felt that embarrassment would prevent them from seeking help for a health issue.

‘It’s a little embarrassing, to go to a doctor and ask for an STI test… But just for the sake of my health I do that.’ (Jenny)

Participants had strong, varied opinions on potentials for future university support and education of international students regarding sexual health.

Many students who had attended residential colleges on university campus felt that the college had provided a strong grounding in sex education and support:

‘I felt like my support system was very, very strong, being in college… But if I was solely applying to the university and staying off campus, I’d say there could be more.’ (Ian)

Many students described compulsory sex education classes hosted by residential colleges as helpful, memorable sources of information. These classes seemed to be particularly resonant compared with the bombardment of online information which students were receiving. One participant described an education session at a residential college that had shaped her understanding of consent:

‘It’s the first time someone told me, like clearly directly told me, you can say no. It’s like something [became] clear for the first time.’ (Rita)

Only some participants mentioned wanting more translated and queer-friendly material. Notably, a few students mentioned avoiding words like sex, sexuality and counselling, which might be associated with culturally taboo topics like sexual promiscuity and mental illness.

Emphasis by participants was also placed on having a safe, comfortable, open environment, which students could access without fear of judgement:

‘I feel like if there’s somewhere to go, that everyone knew about, and was always there, not just booths. Somewhere where you could go and have those sort[s] of questions answered… And you can go without your friends knowing.’ (Gamora)

Interestingly, no participants volunteered the university health service as fulfilling this safe, comfortable description. This reflects previously described perceptions of GPs as meeting health needs, but not offering holistic support.

This study reveals important details about the views and experiences of international students with regard to sexual health. Although this study was conducted at one Australian university, it is likely that the results have resonance for other Australian universities. A pervasive theme of the interviews was consent, sexual harassment and sexual assault. Participants had variable views about what constituted consent, although most had a detailed perception of consent. Nonetheless, many explained they would be hesitant to report occurrences of sexual misconduct, citing concerns of victim blaming, publicity and effects on visa status. Cultural and familial taboos were also highlighted, with participants often describing a shift in mindset and sexual liberation since moving to a more ‘permissive’ Australia. Although university support was perceived to be well-intentioned and comprehensive, in practice, participants felt overwhelmed by the quantities of information provided to them, and they lacked skills to navigate this information. Ideas for future support and education were numerous and varied, with some emphasis placed on compulsory classes, and other students highlighting the need for a safe, non-judgemental place on campus. Participants did not perceive GPs as fulfilling this need; rather, on-campus health services were often described as a place to go with a health problem, rather than to access holistic support.

Participants suggested several potential options for future university support. Significance was regularly placed on the compulsory classes organised by residential colleges, suggesting that similar classes could be helpful for all newly arrived international students. Additionally, the common suggestion of implementing a safe, comfortable space on campus indicates that students do not perceive doctors or health services as being this non-judgemental space. This is a centrally important finding and denotes that campus health services should be ‘rebranded’ as a safe, relaxed space.

Participants often described that moving to Australia had enabled the ‘breaking of taboos’ and enabled a more sexually permissive lifestyle, including a change in attitudes towards sex before marriage and queer relationships. This finding contrasts with a previous Adelaide study by Burchard et al., who concluded that moving to Australia was ‘unlikely to produce a radical change in attitudes towards premarital sexual activity’ in female international students.¹⁷ One reason for these conflicting conclusions may be due to the study by Burchard et al. being conducted via focus groups rather than individual interviews, potentially inhibiting participants from discussing changes in personal sexual attitudes.

The results of this study regarding the perception of GPs and health services reflected a similar finding by Burchard et al., who found that female international students did not identify GPs as a service for general health care, but as a source for treatment of disease.¹⁷ This was also a strong finding of this study, which found that students perceived GPs as resolving illness rather than providing support and holistic care. This suggests that GPs may need to ask international students specifically about sexual health during general consultations.

This study also aligns with the City of Sydney report on international students, which briefly described that sexual health being a culturally sensitive topic, was a barrier to accessing sexual health care.¹⁰ Similarly, results of this study show that cultural sensitivities had often restricted the sex education of international students. Some participants also mentioned that avoiding ‘explicit’ words such as sex, sexuality and counselling might be helpful when targeting international students for educational programs.

The commonly raised experience of international students having minimal sex education before arriving in Australia is also reflective of two previous studies, which found that international students have poorer knowledge of sexual health and low rates of sexual health literacy.^14,15 Similarly in this study, many participants linked their nominal sex education with sexual health being a taboo subject within their culture, religion or family. Several participants in this study arrived in Australia with a poor understanding of sexual health, and some arrived with inherited cultural taboos. Although participants often felt that living in Australia had enabled them to develop their personal beliefs and understanding, this was not always due to a supportive, educational environment, but rather exposure to more sexually permissive attitudes. Support may be needed to help international students navigate the new cultural environment in which they find themselves.

Although cost has been highlighted as a barrier in studies of university students accessing STI checks and contraception usage,^26,27 participants in this study expressed little concern for the financial burden of accessing sexual health. There was a varied understanding of insurance coverage, supporting results found in the United States.^19,20 Nonetheless, no participants reported that cost might dissuade them from accessing appropriate health care. However, it is important to recognise the exception of HIV PrEP, which is not publicly funded for international students. This was raised by one participant in this study as an issue, and Medland et al.²³ indicated that a lack of public funding might be contributing to ongoing high rates of HIV among international students. Additional qualitative research should be undertaken in this area to further elicit barriers that international students face when accessing PrEP.

Very few participants mentioned that they would prefer to have more translated material available. This contradicts the minimal available literature.^5,10 However, this result may have been due to selection bias; recruitment advertisements were in English, and most participants spoke English confidently. Further research specifically into language barriers should be conducted in order to draw strong conclusions on this subject.

This study has several limitations. First, the sample size is relatively small, was limited to international students from one Australian university in a short timeframe, and not all countries of origin were represented by interviewees. As a result, experiences of students from other areas (e.g. North America) or other universities were not represented in this study. In addition, the decision was made not to include questions in the interview about the participants’ specific sexual experiences. This decision was made as the interviewer was not a trained psychologist, and encouraging participants to have difficult conversations might be harmful to their mental and emotional health without appropriate support and care in place. However, this limited the study to a focus on general views and experiences, rather than specific practices.

This study reveals important information about international students’ views and experiences with regard to sexual health and wellbeing. Variable views about consent were held by participants, and there is scope for further research in this area. Cultural and familial taboos were highlighted, and participants often expressed that moving to Australia had allowed them to develop their personal beliefs and understanding of sexual health and wellbeing. Participants frequently considered information from the university to be overwhelming, and struggled to navigate available support networks. Ideas for future support and education were numerous and varied, and emphasised the perceived lack of a safe, supportive space on campus, and the perception of GPs as only treating disease rather than for holistic care.

The misconceptions regarding reporting of sexual harassment and assault, including concerns of victim blaming, publicity and effects on visa status, should be explicitly addressed by Australian universities. It is essential that international students feel comfortable to report sexual harassment and assault if they choose to, and this study shows that for many international students, this is not currently the case.

The authors declare no conflicts of interest.