Migrant and refugee youth perspectives on sexual and reproductive health and rights in Australia: a systematic review

Keywords: Australasia, human rights, migrant and mobile populations, refugee, reproductive health, sexual health, youth.

Adolescent and young adult health has significant, lasting impacts on individuals’ life trajectories.¹ Accordingly, investing in young people’s health is crucial to future societal wellbeing.^1,2 Youth are vulnerable to compromised sexual and reproductive health and rights (SRHR).³ This is especially so for migrant and refugee youth (MRY) who, despite diverse backgrounds and experiences, face similar barriers to services and care.⁴ Australia has a multicultural population, with 30% born overseas.⁵ Thus, a significant proportion of Australian youth come from migrant and refugee backgrounds. Research indicates these youth have worse sexual and reproductive health (SRH) outcomes, lower service engagement and difficulties navigating health care.^4,6,7 Australian MRY face complex socioecological challenges that shape how they experience and understand SRHR.⁸

SRH is a crucial aspect of wellbeing with broad social and economic benefits.^9,10 SRH can only be attained through realisation of SRH rights.¹⁰ These include reproductive rights and sexual rights regarding making informed decisions about what happens, and when, to one’s body.^11,12 Service, education and information access are also vital rights.^10,11 SRHR are tied to women and young people’s welfare and gender equality, and thus key to sustainable development.¹⁰ SRHR encompasses a range of aspects from wellbeing (including fertility, pregnancy and contraception) and sexually transmitted infections (STI) to relationships, gender and sexuality. These aspects are interrelated and inform one another and as such, are examined as a whole in this review.

Australian migrant and refugee populations face poor health outcomes and barriers to care.^13,14 Low SRH service uptake, fuelled by structural barriers, linguistic challenges, and lack of cultural safety, heightens health risks.^15,16 Many cultures have specific SRH constructions, including taboos around sexual activity;¹⁷ moreover, displacement and migration shape SRH knowledge and experiences.¹⁸ While migrant and refugee populations face similar barriers to SRHR attainment, refugees may have particular experiences that further exacerbate vulnerabilities: psychological and physical trauma from conditions in their origin country, hazardous journeys, refugee camps, educational disruption, citizenship and settlement struggles.¹⁹

Australian youth are disproportionately represented in national STI rates,²⁰ and are at risk of undiagnosed and untreated STIs.²⁰ However, MRY have less SRH service knowledge and lower STI testing than their non-migrant counterparts.²¹ MRY thus experience barriers to rights attainment on numerous levels.²² MRY do, nevertheless, find ways to navigate these barriers and enact agency.

Although some research has examined MRY SRH, none has specifically addressed how MRY understand and construct rights. By examining SRH studies through a human rights lens, this review emphasises how MRY construct rights, their strengths and resilience. Our aims were to explore Australian MRY’s SRHR, using a systematic review methodology. The review was guided by the following questions: (1) How do MRY construct SRHR in Australia? (2) What socioecological factors contribute to these constructions?

A mixed-methods systematic review was undertaken to examine MRY’s SRHR constructions, barriers and enablers in an Australian setting. A protocol for this review provides detailed methods.²³

Key subject areas – ‘sexual health’, ‘youth’/‘young people’, ‘migrant(s)’ and ‘refugee(s)’, and ‘Australia’ – were searched across nine databases (Medline, EMBASE, CINAHL, APAIS, ProQuest, PsycInfo, Web of Science, SCOPUS and PubMed), in addition to hand and grey-literature searches. Two reviewers (SNR and SZH) used Covidence review software to screen the title and abstracts of records.²⁴ Full-text screening was undertaken consequently.

Inclusion criteria specified studies that: (1) examined migrant and/or refugee youth; (2) presented MRY perspectives, experiences and attitudes towards SRH; (3) were peer-reviewed qualitative, mixed methods and/or quantitative studies, or grey literature, such as reports and government documents; (4) based on Australian research; and (5) published between January 2000 and March 2021 in English. Studies that did not examine MRY and their attitudes or perspectives; for example, purely epidemiological studies, reports on disease incidence, morbidity and treatment rates were excluded, as were abstract papers, reviews, protocols, letters and opinion pieces. Non-English literature and records published before 2000 were excluded. Table 1 details search terms and selection criteria.

Table 1.  Search terms and selection criteria.

A broad definition of youth was taken, with studies included where the participant group was age 15–24 years, or where researchers defined participants as ‘youth’, ‘young’, ‘young adult’, ‘young people’ or an analogous term. Migrants and refugees included those who voluntarily left home countries, including international students, and those forced to flee conflict or persecution. Studies of first, second and 1.5 generation migrants and refugee, and studies of culturally and linguistically diverse (CALD) populations were included. Records in which MRY were an identifiable sub-group of the study sample were included, such as broader studies of migrant and refugee populations or youth populations, where specific data from MRY was distinguishable and extractable.

Quality assessment was conducted independently by two reviewers using the Mixed Methods Appraisal Tool (MMAT).²⁵ Studies were given an overall score based on percentage of quality criterion met, where one criteria met is 20% and five is 100%.²⁶

Data extraction and synthesis were guided by Thomas and Harden’s thematic synthesis methods,²⁷ and use of QSR’s NVivo 12.²⁸ Full text records were uploaded to NVivo. General study characteristics – date, author(s), setting, study design, data collection method(s), population characteristics, and sampling strategy – were recorded. All findings regarding MRY were extracted. This included all relevant data under ‘results’ or ‘findings’ headings and any participant quotes in other study sections. A process of ‘qualifying’ quantitative data was undertaken in which tabular data was ‘translated’ into sentences and coded along with qualitative data.^29,30

Synthesis was inductive and carried out in three stages. First, the results were coded line-by-line. Codes were then grouped into descriptive themes, resulting in 14 final key themes including ‘sexual behaviour and relationships, ‘contraception and protection’, ‘parents and family’ and ‘healthcare, services and support’. Descriptive themes were then developed into analytical themes, ‘going beyond’ primary study data.²⁷ This ‘going beyond’ involved using the socioecological model and a rights-based framework to develop themes.

Initial data base searches yielded 584 articles. An additional 16 records were identified through hand searching. We included 28 papers in the final review (Fig. 1).

Fig. 1.  Flow diagram of search and study inclusion process.

Study characteristics and quality scores are in Table 2. Eight papers focused on refugees, six on migrant and refugee participants, three on second-generation migrants, four on international students, and eight provided no details of migration/refugee status. Three focused on intergenerational experiences; one mixed-age study included participants aged 19–51 years, and in five studies, participants classified as ‘young’ included some individuals over the age of 25 years. Data specific to MRY was distinguishable from older participants in included mixed-age studies. One study specifically addressed rights but did not examine how MRY themselves perceived or understood rights.³¹

Table 2.  Study characteristics.

We present findings thematically under broad headings of the research questions. Fig. 2 depicts individual, interpersonal, institutional and societal factors identified in this review. This structure ensures research questions are answered comprehensively and presents findings in a way that will be useful to health practitioners. We have endeavoured to present results in a manner that aligns with participants’ views and perceptions.

Fig. 2.  Socioecological factor model.

Three major areas constituted MRY constructions of SRHR: (1) experiences of silence and shame; (2) youth understandings of and responses to risks; (3) navigating relationships and sexual activity.

A common theme across studies was experiences of silence and shame. Stigma surrounding sex,^21,32–39 pregnancy,^{34,36,40–42} STIs,^6,19,36 relationships,³³ and sexuality^43,44 were common within participants’ communities and families. MRY understandings of shame were gendered; women were consistently the subject of shame.^{6,19,21,32–34,41,45,46} The only descriptions of shame befalling men related to sexual orientation.⁴³ Throughout this review, gender is a key individual socioecological factor shaping SRHR constructions.

MRY internalised shame to different extents; from intense shame³³ to mild discomfort and embarrassment^38,39,47 and beliefs that ‘doing sex is not a bad thing’.⁶ Young Muslim women expressed the most shame,³² some believing even accidental transgressions – bumping into a man – were unacceptable.³³ On sexual desire, one woman commented ‘we think it’s wrong, wrong, wrong.’³³ Conversely, many MRY understood SRH as socially taboo without personally considering sex shameful. Youth distinguished their own views from those of their community, navigating interpersonal factors as will be discussed further (see section (2)).^19,21

Shame inhibited discourse. The sentiment expressed by one Vietnamese woman about her community, ‘we don’t talk about sex’,⁴⁷ was reiterated across studies, shared by youth from East and West African, Middle Eastern, East and South Asian backgrounds.^{4,19,32,33,35,36,39,40,48–50} Generally, MRY did not discuss SRH with families.^{21,36,39,40,47,48,50,51} Parents stifled and avoided conversations,^39,48 telling children ‘sex is an adult topic’.³³ Parents reiterated shame and warned children against sex.^19,33,48 Families and communities believed openness would encourage promiscuity.^19,40,42,49 Discussing sex was an admission of sexual activity.³⁴ If MRY mentioned SRH, parents would be judgemental,^4,19,21,35 disappointed,³⁶ uncomfortable and unresponsive.^19,39,40 Some LGBTQI+ youth had supportive yet limited conversations with immediate family about sexuality.⁴³ There were few exceptions of MRY discussing SRH with mothers (none mentioned fathers).^19,32,40

Many MRY discussed SRH with friends, relying on peers for information.^{4,19,21,32,36,45,48} However, occasionally, fear of judgement prevented this, especially with peers from the same background.^4,19 Some asserted SRH discussions were only acceptable with one’s spouse, leaving unmarried youth unable to discuss issues.^19,33 Youth felt silence and shame had negative consequences, impeding understandings of SRHR and risk avoidance.^19,39,46,50

SRH understandings prominently featured STIs, or ‘bad sicknesses’.^6,36,39 Beyond awareness, however, knowledge was inconsistent and often limited.^{4,6,32,33,36,40,42} While HIV was widely known, many struggled to name other diseases,^{6,21,32,33,36,49} and misconceptions were rife; e.g. HIV being a cancer,³² transmissible by mosquitoes,⁵² shared utensils, and proximity.⁶

Botfield et al.²¹ found some MRY were concerned about not knowing whether they needed testing or treatment. Conversely, many believed that ‘you can realise’⁶ when infected.^6,19,52 Despite not knowing symptoms, MRY believed their bodies would exhibit tangible signs such as ‘changing in your menstrual cycle’.⁶ Someone with HIV would have ‘a dead look’, and those with STIs could be determined by appearance, reputation or behaviour.⁶

Disengagement with STI risk was evident, even when MRY feared infection. For some, fear was immobilising, one woman being ‘too scared’ to learn about STIs,³³ another admitting she would ‘rather not know’ she had an asymptomatic STI.²¹ Many believed they were not personally at risk.^6,19,36 Among refugee youth, whose perceptions were shaped by socioecological factors of differing educational experiences and migration history, there was a common misconception HIV was ‘not that risky’ in Australia.^6,40,52

Overall, pregnancy was a greater concern than STIs.⁴⁹ As evidence of pre-marital sex, unintended pregnancy brought personal and communal shame.^33,34 Filipinas and African-background women considered early pregnancy a major problem within their communities.^36,42,51 MRY understood pregnancy as a gendered risk; discussions focused on women, with consequences solely impacting mothers.^6,34 Children were prized in many communities, but non-marital pregnancy was ‘the worst thing that could happen to anyone’.³⁴ Pregnancy was predominantly considered a social risk, having ramifications beyond the mother.^34,41 Forced marriage, ostracism, being ‘kicked out’, parental wrath and mistreatment were commonly hypothesised consequences of non-marital pregnancy.^34,36,41 Only those who had experienced pregnancy discussed personal consequences of disruption to livelihood, education and opportunity loss.^36,41,42

The social acceptability of pregnancy varied. Filipina and Sudanese mothers described their lives as limited and irrevocably altered by pregnancy.^36,40 However, among young African mothers, pregnancy was generally viewed positively; motherhood turned girls into women, gave them purpose, responsibility and respect.^40–42 Women who experienced early pregnancy had low SRH literacy before conception. Pregnancy was the first time these women discussed SRH, learned about contraception and, for some, discovered intercourse led to pregnancy.^19,40,53

Concerns about SRH risks did not necessarily bring precautionary action. While some youth demonstrated good understanding of preventative measures,^6,36,51 studies revealed prevalent misconceptions,^{33,40,45,49,51,53} inconsistent use, suspicion and apathy.^36,51,53 Condoms were most widely known, mentioned in all studies that discussed protection.^{6,19,21,32,33,36,38–40,45,49,51–53} Many MRY lacked understanding of how preventative measures worked,^33,40,51,53 and were unaware or unconvinced they needed consistent use.^36,51,53

Fatalism was evident in attitudes towards protection, one woman asserting infection ‘would happen no matter... what you’re using’.³³ Misconceptions that the contraceptive pill causes infertility were common.^{33,40,45,49,51,53} Other concerns included weight gain, cancer, hormonal imbalance and unspecified long-term harm.^40,53 Young women feared implants and contraceptives that disrupted cycles.^40,53

Perceived social risks of protection and contraception informed attitudes towards physiological risks. Youth forewent protection because they feared others discovering sexual activity.^32,42,51,53 Many MRY asserted commitment negated need for protection. Trust and fidelity were sufficient: ‘if you don’t play around, you don’t get the diseases’.⁶ Conversely, protection indicated mistrust, or implied partners had diseases,¹⁹ and was associated with promiscuity.^19,40 Partners refused protection and used accusations of infidelity or lack of love to coerce young women into unprotected sex.⁵³

Social risk featured prominently in the study by Botfield et al.³⁴ of pregnancy and abortion. MRY described abortion as deeply stigmatised within communities, and technically more unacceptable than non-marital pregnancy.³⁴ Unlike pregnancy, abortion can be hidden and therefore termination was preferable.³⁴ Youth asserted they would undergo abortion and believed parents would encourage this to avoid social consequences of pregnancy.³⁴

MRY constructions of intimacy frequently featured abstinence and virginity.^33,46 Abstinence mitigated physical and social risks of sex.⁶ For those who considered sex sinful, abstinence removed risks of personal degradation.³³ These values were salient across diverse backgrounds.^{32,33,36,43–46} LGBTQI+ youth described being alienated from hypersexuality of mainstream white queer identities.^43,44 As one woman noted, sexuality did not change her values, leading her to forego ‘sex outside marriage because it’s part of my faith’.⁴⁴

Constructions of virginity were gendered. Male and female participants valued abstinence, but only women were considered ruined by pre-marital sex.^6,19,33,45 Female virginity was significant for marriage prospects.^6,45,47 Some male MRY would not marry or date women who were not virgins.⁶

Abstinence was practiced varyingly. Some abjured pre-marital sex as completely unacceptable.³³ Young Muslim women held the most strict practices,^32,33 avoiding male interaction and suppressing ‘desire to have sex and stuff’.³³ Purity was upheld through ignorance: one woman deliberately distracted herself during school sex education,³³ while others were happy to have not received education.³² Young women in two studies avoided tampons because they compromised virginity.^33,36 Some considered non-sexual relationships acceptable. Others asserted pre-marital sex was justified if one was in love and planned on marriage.^33,39,45

MRY felt navigating ‘healthy relationships’ was an important aspect of SRH,^21,37,46 albeit something not taught.^21,48 Frequently, relationships were hidden, particularly from parents.^{4,19,33,36,37} This was especially so for LGBTQI+ youth, who often kept relationships and sexual orientation secret.^21,43 MRY lacked understandings of unhealthy relationships, displaying limited sexual autonomy. Young African-background women noted that among peers, controlling, violent behaviour was common and romanticised.^37,46 Youth only discussed consent in two studies,^37,38,46 but there were multiple descriptions of non-consensual experiences across studies.^{6,21,40,50,52} MRY were pressured into sexual acts, unprotected sex, and having children.^6,21,40,50 Youth saw sexual violence as limited to stranger rape, did not acknowledge marital rape, and discussed pervasive beliefs that consent in relationships is automatic and irrevocable.^21,33,37,46 Rather than their own rights, young Muslim women asserted husbands’ rights to wives’ bodies, and wives’ duties to provide sex.³³ MRY described victim blaming being common within their communities, asserting ostracism and shaming prevented victims reporting and getting support.^38,46

Ensuring young people’s SRHR is invaluable to sustainable development.^2,9 Thus, SRHR outcomes for MRY, which represents a significant proportion of Australia’s population with specific needs and experiences, are critical to the overall wellbeing of Australian society. This review synthesised Australian MRY’s constructions of SRHR and examined socioecological factors informing these constructions. While there was a paucity of literature on MRY constructions of rights, we found that SRHR constructions were diverse and complex, with key areas of congruence. As our model highlighted (Fig. 2), MRY contended with myriad factors intersecting across socioecological levels. The differing ages, educational experiences, and settings of participants across included studies may influence the ways in which they navigate and construct SRH beliefs, relationships, and social structures. Nevertheless, we identified certain shared experiences, particularly in education, family interactions, institutional engagement, and cross-cultural navigation. Gender dimensions pervaded MRY constructions of SRHR.

Our synthesis identified SRH taboos as ubiquitous in MRY experiences, indicating youth across various backgrounds navigate stigma and prohibitions. Significantly, shame was mostly externally placed on individuals or certain subjects, with MRY distinguishing between what they themselves felt and the prevalent discourses in their contexts. These findings are consistent with those of Ussher et al.⁵⁵ on migrant women’s active negotiation of shame, rather than passive internalisation. Our findings differ from those of general Australian youth populations, where families were more frequently a source of SRH information.^56,57 MRY experiences of family silence are more similar to youth in LMIC in Africa,^58–60 Asia,^60–62 Middle East,⁶³ the Pacific.⁶⁴ Shame around SRH has been noted to impinge on discourse and information-seeking.^16,17 Lack of avenues for SRH discussions impedes rights to information. Moreover, low SRH literacy impinges other rights, increasing vulnerabilities to SRH risks.¹⁷

We found that MRY constructions of risk and navigation of relationships involved balancing biomedical and social factors. Overall, there were concerning deficits in understanding of health risks, preventative measures and agency in relationships. Consistent with data from the broader Australian youth population, MRY perceived themselves as having low STI risk.⁵⁶ Our findings parallel research on social risk as significant in SRH decision-making, where protecting ‘culturally valued social resources’ is prioritised.^65,66 A social risk approach may explain why MRY did not necessarily engage in risk prevention. For example, cultural values of childbearing and stigma around infertility fuelled fears of oral contraceptives, turning a risk-prevention method into a perceived risk. This highlights the complexity of rights and agency. While youth found ways to navigate restrictions, rights around bodily autonomy were significantly compromised. We found multiple descriptions of non-consensual experiences, and a concerning lack of consent vocabulary and understandings. We found that MRY do hold agency, but, as with young people in areas of East Africa,^58,67 East and South Asia,^60,62,68 and the Pacific,⁶⁴ this was compromised by contextual, structural and social factors. Often, MRY engaged ‘subtle’ or ‘thin’ agency, navigating within and around constraints.^58,67

Relationships were highly significant to MRY; relationships with family, community, peers and partners could impede and enable rights actualisation. Migration disrupts social networks, heightening the importance of family and community connections in resettlement, or bringing pressure to maintain bonds.⁶ Australian cities contain stratified areas with high concentrations of specific cultural groups.⁸ Many Australian migrants and refugees come from non-Western cultures that are collectivist-oriented.⁶⁹ The importance of relationships to MRY’s SRHR constructions is thus unsurprising. Greater intergenerational communication in families around SRH issues has been shown to bring myriad benefits.⁵⁴ Given the importance of interpersonal relationships to youth’s SRH constructions and behaviours, educational and service improvements that centre these areas may be particularly valuable.

We found striking similarities across MRY experiences of education and services. The common experience of inadequate education may explain MRY’s knowledge gaps. The focus on biomedical and physiological SRH in formal education likely contributed to MRY’s difficulties articulating sexual autonomy and navigating relationships. Given MRY concerns regarding social risks, education that takes a purely physiological approach will fail to fully engage this population. While the general Australian youth population also report variable content and depth in school sex education,⁵⁶ various factors, including parental silence, service barriers and cultural mores, may make it harder for MRY to supplement inadequate education. MRY’s ignorance of SRH services is consistent with comparable studies in other high-income countries.⁷⁰ Youth’s misgivings about health and legal support overwhelmingly related to social risk; fears of negative repercussions for seeking support and that doctors would breach confidentiality. Mistrust indicates services have not effectively engaged MRY or presented themselves as safe spaces. MRY clearly asserted the need for greater cultural sensitivity. Having culturally sensitive education and care allows awareness of the influence of cultural factors in decision making without reducing youth’s SRHR constructions to their cultural background.

Our findings suggest that to successfully engage and support MRY, future policy and practice must recognise the social and relational aspects of SRH. School curricula should be adapted to include education on emotional and social factors. Having services that are aware and sensitive to cultural factors, without being reductive, are also essential. Given low awareness of services, promotion programs that inform MRY on local services are necessary, perhaps through targeted social media advertisements or within schools. Health workers must assure MRY of confidentiality, and options for anonymous support, such as virtual or phone helplines, may be beneficial.

We identified a significant gap in the literature on rights. How MRY understood and constructed rights was not directly discussed in any studies, limiting our analysis to implicit discussions of SRHR. There was no indication MRY recognised their entitlement to SRH rights. Additionally, there is a clear under-representation of male MRY’s SRH perspectives. Half the eligible studies comprised solely female participants. Women are disproportionately impacted by SRHR issues, contending with prohibitive gender norms and power imbalances,⁷¹ as evidenced by gendered constructions of SRH throughout this review. Nevertheless, understanding how men experience and uphold gender dynamics is important to holistic SRHR improvements.

This review took a broad definition of MRY. Therefore, we were unable to capture nuanced perspectives of specific groups within this population. There was limited scope to examine differing perspectives and understandings such as those between older and younger MRY, and MRY with differing educational attainment. Due to the small literature pool, sub-group analysis based on ethnicity, religion or cultural background was unfeasible. There was an uneven distribution of backgrounds, and participants were not representative of Australia’s migrant and refugee demographic makeup.⁵ Nine papers exclusively involved African-background participants, with under-representation of youth from other areas. Similarly, we were unable to perform significant gender comparisons due to limited data on male participants. Future studies using large samples should consider possible differences by sociodemographics in how MRY may understand their SRH rights.

Some included studies also lacked detail on the methodology used, specifically theoretical frameworks, limiting our findings. Moreover, studies of lower quality, receiving MMAT scores of 40 or 60%, were still included in the final analysis. Future studies must include a detailed methodology and theoretical framework for a better understanding of MRY’s SRH rights.

While there was a paucity of exploration of youth rights constructions and inadequate investigation of male MRY experiences, this review provides crucial information on how Australian MRY experience and construct SRHR. We found social aspects of SRHR are deeply significant to MRY, yet appear under-represented in education and service approaches. To ensure sustainable impact, health practices must be situated in MRY’s structural, emotional, cultural, and social conditions. Our findings will guide service delivery to optimise MRY’s SRHR outcomes, not just in Australia but more widely in the region and other multicultural populations.

Data sharing is not applicable as no new data were generated or analysed during this study.

The authors declare no conflicts of interest.

This review was written as part of a funded research project: Australian Research Council Discovery Grant Project. Project ID: DP200103716.