Sexual And Reproductive Health Of Migrant And Refugee Women
Sexual and ReproductiveHealth of Migrant and RefugeeWomenResearch Report andRecommendations for HealthcareProviders and Community Workers
Funding and research teamThis research was funded by an Australian Research Council Linkage Grant LP130100087 to theCentre for Health Research, School of Medicine, Western Sydney University, in conjunction withFamily Planning New South Wales (FPNSW), The Community Migrant Resource Centre (CMRC) andCentre for the Study of Gender, Social Inequities and Mental Health, Simon Fraser University,Vancouver, Canada.The chief investigators on the project were Jane Ussher1, Janette Perz1 and Renu Narchal1. Partnerinvestigators were Marina Morrow2, Jane Estoesta3, Jane Wicks3 and Melissa Monteiro4. ChristineMetusela1 was the research co-ordinator, Alexandra Hawkey1 a doctoral candidate, and BrendaJamer2 and Sevinj Asgarova2 co-ordinated the Canadian data collection. The research was approvedby Western Sydney University, Simon Fraser University, Vancouver Coastal Health, Fraser Health, andFamily Planning NSW Ethics Committees.1 WesternSydney University; 3 Simon Fraser University; 3 Family Planning NSW; 4Community MigrantResource CentreAcknowledgementsWe thank our community interviewers: Salwa Alhag, Tabitha Ajak, Naima Abdullah, Mala PunniaMoorthy, Nabila Qalandarzadah, Hela Jaffar in Australia, and Hoda Nassar, Rahma Abdullahi, HalaHabibi, Rima Hijazi and Adriana Paz in Canada, and also the following people and communityorganisations for assistance with recruitment: Conscila Emilianus, Faiza Shakori, Nuha Razaq, NazifaAli, CMRC, Options for Sexual Health, East Van Youth Clinic, Evergreen Community Health Centre,Burnaby New Canadian Clinic, Surrey New Canadian Clinic, and Healthiest Babies Possible,Vancouver Coastal Health. We also thank all the women who took part in interviews and focus groupsto share with us their experiences of sexual and reproductive health. Finally, we thank all of thecommunity stakeholders and service providers who gave feedback on the report.Report prepared by Jane Ussher, Christine Metusela, Alex Hawkey, Janette Perz, and formattedby Melinda WolfendenSuggested formal citation:Ussher, J.M., Perz, J., Metusela, C., Hawkey, A., Morrow, M., Narchal, R., Estoesta, J., Monteiro, M. (2017)Sexual and reproductive health of migrant and refugee women. Research report and recommendationsfor healthcare providers and community workers. Western Sydney University.For further details about the research see:Ussher, J. M., Perz, J., Metusela, C., Hawkey, A. J., Morrow, M., Narchal, R., & Estoesta, J. (2017).Negotiating Discourses of Shame, Secrecy, and Silence: Migrant and Refugee Women’s Experiences ofSexual Embodiment. Archives of Sexual Behavior. DOI:10.1007/s10508-016-0898-9Hawkey, A., Ussher, J. M., Perz, J., & Metusela, C. (2016). Experiences and Constructions ofMenstruation Across Culturally and Linguistically Diverse Migrant and Refugee Women. QualitativeHealth Research, DOI: 10.1177/1049732316672639.An electronic copy of this report can be downloaded from:www.westernsydney.edu.au/SRH CALD Report.pdf
ContentsIntroduction. 2The Research Study . 2Research Methodology . 2Interviews . 3Data analysis . 3Menarche, Menstruation and Menopause . 6Fear, shame and secrecy at menarche . 6Absence of communication about menstruation . 6Mother-daughter communication . 6Limited knowledge of the function of menstruation . 6Cultural and religious restrictions during menstruation . 6Menstrual difficulties . 6Menopause . 6Contraception and Family Planning . 10Culture and religion . 10Experiences of contraception use . 10Abortion. 10Sexual Knowledge and Communication . 14Premarital sexual knowledge and communication . 14Premarital sex and relationships with men . 14Marital sexual communication and consent . 14Premarital Virginity and Female Circumcision or Female Genital Cutting (FGC) . 18Meaning of Female Genital Cutting (FGC). 18Experiences of FGC and impacts on health and sexuality . 18Sexual Health Knowledge and Practice: Cervical Screening, HPV and Sexually TransmittedInfections (STIs) . 22Knowledge of cervical screening, HPV and STIs . 22Barriers to cervical screening and HPV vaccination . 22Experiences of and worries about STIs. 22Sexual Health Information and Support – Experiences and Preferences . 25Experiences of consultation with health care professionals . 25Preferences for sexual health information. 25Moving Forward and Future Research . 28References . 30Appendix 1 . 321
IntroductionSexual and reproductive health is a keycomponent of quality of life, with utilisationof sexual and reproductive health servicesassociated with positive mental health [1].However, these services are underutilisedby migrant and refugee communities [2-4].This can result in a lack of information forinformed decision-making and poor sexualand reproductive health outcomes amongmigrant and refugee women [4-6].There are a range of reasons why migrantand refugee communities underutilisesexual and reproductive health services [2,7]. Social and cultural norms sometimesmake open discussion about sex andsexuality difficult [8-10]. Consequently,health concerns may not be addressed withfamily members and healthcare providers.As a result, women may have poorknowledge of, and access to, contraception,and feel ill equipped to articulate theirsexual rights [11], exposing them to STIs andunwanted pregnancies.Where premarital sex is discouraged,parental and community attitudes caninfluence women’s contraceptive educationand prevent access to the HPV vaccine [12,13]. If it is seen as inappropriate andunnecessary for unmarried women toaccess sexual and reproductive healthservices [5, 6], such women may beashamed to obtain contraceptives [14], orbe fearful of parents or the communityfinding out they are using contraception[15]. Personal reputation or family honourmay then be jeopardized if it is known thatthey are engaging in premarital sex [4, 9].How diseases and treatment of illness aresocially and culturally understood may be abarrier to accessing sexual and reproductivehealth services for some women. Infectionsand diseases may be seen to be determinedby a god or by fate, therefore contributingto avoidance of sexual health screeningbehaviours.There is a need for health providers torecognise the social norms and practices ofsexual and reproductive health withinmigrant and refugee populations, in orderto provide culturally safe medical care,health education, and health promotion,and to increase capacity to access sexualand reproductive services [10, 16-18].The Research StudyThe aim of our research was to examinehow sexual and reproductive health isexperienced and understood by recentmigrant and refugee women, living inSydney Australia and Vancouver Canada.This allowed us to identify unmet sexual andreproductive health needs and barriers toaccessing information and services [19, 20].We interviewed women from a range ofrecent migrant and refugee communities,including Sudan, South Sudan, Somalia, Iraq,Afghanistan, Sri Lanka (Tamil), India(Punjab) and Latin America. In thisdocument we present participant accountsof experiences of sexual and reproductivehealth. This includes: menstruation andmenopause;contraception;sexualrelationships; female genital cutting; sexualhealth screening; and use of sexual healthservices.We draw on these findings to outlineimplications for health services and providerecommendations to healthcare providersfor culturally safe care of migrant andrefugee women’s sexual and reproductivehealth needs.Research MethodologyA total of 169 women participated betweenJuly 2014 and March 2016. In-depth one-toone interviews were carried out with 84women. Additionally, 16 focus groups wereheld with a total of 85 women [20].Women were aged between 18 and 70years, with 35 being the average age. 54%were married, 2% living together but notmarried and 44% were single (including2
divorced and widowed). Participants hadarrived in Australia or Canada an average of6 years before the interview. The majorityidentified with Islamic religion with 66%Muslim, 20% Christian, 7% Hindu, 2% Sikh,1% Buddhist and 5% non-practicing (SeeFigures 1-4 for demographics).Australia and Canada were chosen as thesites for the research as they are similargeographically, economically and politically,and have comparable migrant and refugeepopulations.The specific cultural groups were chosenthrough consultation with communitystakeholders who are involved withsupporting or providing sexual andreproductive healthcare to migrant andrefugee populations. The cultural groupsselected (Figure 1) were recognised as beingunderrepresented in previous sexual healthresearch, and were identified asunderutilising current sexual healthservices, despite reflecting a significantproportion of the recent culturally andlinguistically diverse 1 migrant population ofAustralia and Canada.reproductive lifecycle from menarche tomenopause, and on sexual health practices,including sex before marriage, consent,pleasureanddesire,contraceptionknowledge and use, and sexual healthscreening.Data analysisInterviews were translated by thecommunity interviewers, and transcribedverbatim, with actual names replaced withpseudonyms. Thematic analysis was used toanalyse the data. This is a qualitativemethod for identifying, reporting andinterpreting patterns or themes withininterviews [21].Although differences were found within andbetween women from different culturalbackgrounds there was no notabledifference between accounts of womenfrom Australia or Canada. Therefore, in ourpresentation of women’s accounts below,we have identified cultural background butnot country of residence post-migration.We acknowledge that the findings may alsobe applicable to women from other culturesincluding non-migrant women.InterviewsTrained community interviewers withineach of the language and cultural groupswere involved in recruiting and interviewingthe majority of women in both Sydney andVancouver.In Sydney, participants with conversationalEnglish had the option of being interviewedin English by one of the research team.Women gave informed consent andinterviews and focus groups were digitallyrecorded. Topic areas focused on the1The term “culturally and linguistically diverse”(CALD) is used in Australia to describe peoplewho have a cultural heritage different from thatof the majority of people from the dominantAnglo-Australian culture, replacing thepreviously used term of people from a “nonEnglish speaking background” (NESB). As thisterm is not used in Canada, we are defining oursample as ‘migrant and refugee women’.3
Figure 1: Cultural background of participants7%Cultural liSouth Sudanese22%Sudanese10%Tamil5%Figure 2: Religion of duSikh66%BuddhistNon-practicing4
Figure 3: Relationship status of participants5%Relationship status16%Married54%Living together gure 4: Education level of participants18%Education Nil22%No response5
Menarche, Menstruation andMenopauseFear, shame and secrecy at menarcheManywomenhadreceivednoinformation about menstruation prior tomenarche and described the experienceas being isolating, shocking andfrightening. They often had no idea whatmenstrual blood was, where it came fromor what it meant. Some women mistookmenstrual blood for faeces or urine,thought they were sick or injured, orbelieved they were being punished forwrong doing [19].Absence of communication aboutmenstruationMany young women concealed their firstperiod and did not discuss it with anyone,becauseoffeelingsofshame.Menstruation was described as aforbidden topic in many families. Ifwomen had received information andsupport at menarche it was primarilyfrom their mothers, or from femalefriends and relatives. Some women hadreceived a biological explanation ofmenstruation at school. This informationand education was often brief, and did notalleviate feelings of shame.Mother-daughter communicationThe majority of women wanted theirdaughters to avoid the negativeexperiences they had been through atmenarche. However, some women feltembarrassed talking about periods withtheir daughters. This acted as a barrier toproviding menstrual information andsupport. Women who had received helpfrom community workers in providingmenstrual education were more confidentabout talking to their daughters.Limited knowledge of the function ofmenstruationMenstruation symbolised a girl becominga woman, and in some cultures resulted inan expectation of early marriage.However, the majority of women told usthat they had no knowledge of the linkbetween menstruation and reproductionbefore their first period. Some womenonly learnt about the function ofmenstruationwhentheybecamepregnant. Those women who did knowthe purpose of menstruation had learnedthrough science classes at school, orthrough informal mechanisms, such asfemale friends and family.Cultural and religious restrictionsduring menstruationMenstruating women were commonlyconsidered dirty and unclean. Somewomen from Afghanistan and Iraq weretold not to shower during menstruation,as this was thought to increase pain andbleeding. In a few instances, womenpracticed shower avoidance for up to fourdays. Women who identified as Muslim orHindu were prohibited from visiting holysites, praying or touching holy books.Menstruating women were also exemptfrom fasting at Ramadan.Most participants avoided sexual contactwith their partners during menstruation.Blood was positioned as dirty and a wasteproduct, and having sex duringmenstruation seen as unhealthy forwomen and their partners. Menstrual sexwas religiously prohibited for Muslimwomen.Menstrual difficultiesMany women reported menstrualdifficulties, including severe pain, heavybleeding, and extended bleeding. Only aminority of women had discussed suchdifficulties with a health care professional.Women who had experienced femalecircumcision were concerned aboutinfection or build-up of menstrual blood.Some women experienced negativepremenstrual changes, both physicallyand psychologically. Social and culturalnorms meant that premenstrual distresswas often not recognised or discussed.MenopauseMany participants had poor knowledge ofmenopause. It was commonly viewed asan illness or sickness resulting in negativephysical and psychological changes to thebody. Women wanted more informationabout menopause and how it might affectthem.6
Some women were marriedimmediately following menarcheTalking about menstruation is consideredshameful for some migrant and refugeewomenIn Sudanese culture it is shame to talkabout it [periods] (Saba, age 48, Sudanese)I also associate a period withshame something dirty and somethingto feel bad [about], it’s something to feelashamed of. (Latina Focus Group)Young girls may have poor knowledgeof menstruation prior to menarcheI had no idea what menstruation meant,I had never even heard about the word. Itwas quite scary for me. I would say I waskind of horrified that something waswrong with me or I might have hurtmyself. (Shiwa, age 23, Afghani)When the girls get their period they canbe married to a man. (Somali Focus Group)In South Sudan, when the girl has thefirst period, that means you areconsidered as a woman . . . it’s associatedwith marriage . . . you’re going to getmarried and you are going to havebabies. (Akoi, age 40, South Sudanese)I remember my uncle’s wife told mydad [that I had my first period] andthat is how I got engaged and marriedby 14. Before knowing anything I wasalready a mother. (Minoo, age 32, Afghani)In some migrant and refugee culturesmenarche is celebratedIt's a big ceremony it's called a sareeparty here [Australia] (Tamil Focus Group)During that time, people celebrate, andpeople dancing and people killing thisbig cow to celebrate, and different typesof foods are cooked for the celebration(South Sudanese Focus Group)At menarche a girl becomes a woman,which can lead to restrictionsYou start bleeding and you become awoman. (Amaal, age 42, Somali)You need to change your manner, the wayof sitting, you can’t play outside withyour friends, it’s different. (Raana, age 43,Iraqi)You can’t play around like a child again . . .I didn’t like having to grow up. (Lokoya,age 42, South Sudanese)Migrant and refugee women may havepoor knowledge of menstruation as areproductive functionFor me I didn’t know, I mean like thatI will become pregnant, the first timeI started bleeding. Our parents werenot educated. They didn’t know howto communicate with their childrenbecause they were less educated (SomaliFocus Group)7
Migrant and refugee women mayneed information and resources tohelp prepare their daughters formenarcheI was scared to tell her about theperiod because my daughter mightmisunderstand me But I went to amigrant resource centre and there wasa lady talking about women's health.She talked about periods and how totell daughters. I learnt from thatsession and it encouraged me to tellmy daughter. (Sudanese Focus Group)I don’t want my daughters to beshocked like I was (Madina, age 45,Iraqi)Menstrual and premenstrualdifficulties were common, but rarelydiscussed with health careprofessionalsI have a very strong constant painthat was so bad and so strong that whenI had my three miscarriages I didn’trealize that those were [miscarriages]because I’ve always had very heavyperiods and a lot of blood andbleeding for many days. (Latina FocusGroup)Whenever I have my PMS I’m verymoody I’m very emotional sometimesvery aggressive as well Well my familydoesn’t know how to react to it theyjust tell me to shush and go away Female circumcision (or genitalcutting) may be associated withmenstrual difficultiesWhen you got periods, that’s why yougot sick, because there is no space tocome, the period. (Hasina, age 25,Somali)My cousin was in the countryside inSudan and she had this badcircumcision which closed everything.So when she has her period, itdoesn't come out and it just stays inher tummy and poisons her bodyand she died. That's why people are soscared. (Sudanese Focus Group)Migrant and refugee women may havepoor knowledge of menopauseI would not want my period to stopbecause this makes me imagine that Iwill be getting ill, and blood will beaccumulated in my body and I willnot have any more energy (Arifa, age 48,Iraqi)But my heart says they [periods]should stop as I feel anxious. I feel Iwill feel better if they stop (Zinat, age45, Punjabi)(Fahmo, age 23 Somali)8
Recommendations Regarding Menstrual Healthcarefor Migrant and Refugee Women: Awareness of cultural sensitivities surrounding discussion ofmenstruation for migrant and refugee womenAwareness of the association of menarche and marriageabilityAwareness of cleansing rituals post menstruationInformation and resources for community workers on menstruation,premenstrual distress and menopause needs to be availableRecognition of menstrual problems among migrant and refugee women(e.g. pain and heavy bleeding; menstrual difficulties following femalecircumcision or genital cutting (FGC); consult with FGC networkAwareness that young women may have poor knowledge of theassociation between menstruation and fertility. This may haveimplications for unplanned pregnancy and contraceptionEncouraging schools to engage with parents in developing programs ofeducation about menarche and menstruationMenstrual Healthcare Resource and SupportNeeds of Migrant and Refugee Women: Menstrual education and information to help mothers preparetheir daughters for menarcheInformation on menstrual health conditions such as painful orheavy bleeding and fibroids, pelvic inflammatory diseaseEncourage women to seek help if they have heavy menstrualbleeding; support the use of contraception for menstrualdifficulties e.g heavy bleedingMenstrual education for prevention and early treatment ofreproductive cancersEducation on anatomy of menstruating body, from whole lifebody perspective and how bodies change e.g. female genitaliaand what is ‘normal’Menstrual and fertility education to prevent unintentionalpregnancies; e.g. through Life Education NSWMenstrual education to include the use of sanitary products,including tamponsInformation on premenstrual change - what it is; what toexpect; prevention and supportInformation on menopause - what it is; what to expect; support9
Contraception and FamilyPlanningFor the women in our study, the primarysource of contraception information wasfemale friends and relatives, followed bythe media. Women described piecingtogether their knowledge throughmultiple sources, including formal andinformal learning. Some women had littleknowledge of contraception due to pooreducation in their countries of origin orpersonal disinterest.Condoms and the contraceptive pill werethe methods most women knew about.However, beliefs some women held aboutsuch methods were not always medicallysound [22].Culture and religionAmong some Muslim women the use ofcontraception was strictly forbidden as itwas considered to be killing a ‘child’.Many women were expected to reproduceuntil they were no longer fertile.Christian women from Dinka tribes ofSouth Sudan stated that it was culturallyunacceptable for a husband to have sexwith his wife while breastfeeding, thusacting as a birth spacing mechanism.Unmarried women were forbidden fromcontraception knowledge or use. Manymarried women needed the agreement oftheir husband to use contraception. Insome cases, parents and in-laws wereinvolvedinthedecision-making.Contraception was mostly used after thefirst child was born.Across all cultural groups there wereexpectations to have children, with apreference for boys. Amongst SouthSudanese, Sudanese and Somali womenlarge-sized families were expected.Smaller family sizes were desired amongPunjabi and Tamil women, as long asthere was at least one boy child.Experiences of contraception useThe use of contraception was fraught withworry and concern due to feared sideeffects. Concern about these side effectsresulted in some women avoiding use ofany form of contraception. However,unplanned pregnancy was also a concern,and many women told us that theywanted contraceptive education forthemselves and their community. Naturalmethods of cycle calculation andwithdrawal were commonly used.However many women reported thisended in unplanned pregnancies.The contraceptive pill was tried by anumber of women, but was oftendiscontinued due to negative side effects.These included headaches, weight gain,and changes in mood. Women alsoworried about the impact of the pill onfuture fertility. Women reported mixedexperiences with IUD’s, contraceptiveinjections and implants with manyreporting heavy or irregular bleeding as aside effect contributing to discontinueduse. Few women used condoms and thosewho did described a negative impact onsensation.AbortionA number of women had undergoneabortion before and after migration.Although religiously forbidden, somewomen and their husbands consideredabortion acceptable in the case offinancial pressure or in very earlypregnancy. Discussing abortion withothers was taboo, so it was conducted insecret.10
Many migrant and refugee womenhave limited or inaccurateknowledge of contraception andfertility controlI have no idea about contraception(Akeck, age 30, South Sudanese)The two sides of the IUD close the twopassages to tubes that take you to theeggs sperm can’t get through andthey have to return back (Sharifa, 43,Iraqi)Just the condom for prevention I don’tknow anything else (Ara, 34, Afghani)I wanted to know more aboutcontraception but at that time therewas no internet and nobody wasaround to give me any kind ofknowledge and no books that I couldrely on. (Wafa, age 40, Sudanese)Due to poor knowledge ofcontraception, migrant andrefugee women may haveunplanned pregnanciesMy husband would try to pull out tonot get pregnant, but despite that Igot pregnant with my son (AfghaniFocus Group)After my first baby I took pills, while Iam using them I fell pregnant fivetimes. I did abortion because I didn’twant more children. (Najiba, age 64,Iraqi)I didn’t use any pills or condoms, Imade a mistake on the day’scalculation and fell pregnant with mysecond child (Zarina, 32, Tamil)Many migrant and refugee women havefears and negative past experiences usingcontraception (Figure 5)They gave me shots and my period has completely stopped I just wonder if it lateron will create complications. So all those periods just stay in and they gather up,right? (Anosha, age 30, Afghani)Contraceptives will cause a lot of problems, sometimes they say you will have ablockage, sometimes they will say, you will bleed to hell after that (Akoi, age 40, SouthSudanese)If they take that birth control it might make them not to have kids anymore, that’sthe big issue (Arliyo, 26, Somali)Figure 5: Negative Experiences and Misconceptions Surrounding Contraceptive Use11
Religious and cultural beliefs maybe a barrier to contraception use formarried and unmarried womenNo the religion does not allow women to use contraceptives (Hido,age 68, Somali) there is no need to stop pregnancy because you’re not evensupposed to get pregnant before you are married and a womanis not supposed to have sex before she is married. (Maano, age 19,Somali)No I never use it [contraception], my religion and culture allowit only if the woman is sick women don’t normally usecontraception, maybe one in one hundred would use it (Saafi, age 43,Somali)There are cultural and familypressures for women to have childrenIf you don't have baby, you can't be in theculture (Tamil Focus Group)Sometimes you don’t have a choice [abouthaving a baby] the family, they’recontrolling. You are not you and yourhusband only (Somali Focus Group)Some women wanted contraceptioninformation and educationSo this is a real education that women need to know, theyneed to learn that you have to stop having babies, usingcontraception (Akoi, age 40, South Sudanese)That’s something that I want to know about - if you don’twant to have kids so let’s say safe sex and usage ofcontraceptives (Setara, age 23, Afghani)12
Recommendations Regarding Contraception and FamilyPlanning for Migrant and Refugee Women: Language and culturally appropriate information and education about variousmethods of contraceptionAddressing misconceptions about methods of contraception duringconsultationsWhere appropriate, involving husbands in discussions of available methods ofcontraceptionUsing the term ‘women’s health’ instead of ‘family planning’ can may be moreculturally acceptableAwareness of the social and cultural sensitivities that migrant and refugeewomen may have regarding contraception use and not to assume knowledgeon the part of patientsRecognising that unmarried women, and married women wanting to usecont
The chief investigators on the project were Jane Ussher1, Janette Perz and Renu Narchal1.Partner investigators were Marina Morrow2, Jane Estoesta3, Jane Wicks3 and Melissa Monteiro4.Christine Metusela1 was the research co-ordinator, Alexandra Hawkey1 a doctoral candidate, and Brenda Jamer2 and Sevinj Asgarova2 co-ordinated the Canadian data collection. . The research was approv
Blueprint for Sexual and Reproductive Health, Rights, and Justice Page 1 Contents Executive Summary 02 Introduction 15 Principle 1: Ensure that Sexual and Reproductive Health Care is Accessible to All People 17 Promote Comprehensive Access to Sexual and Reproductive Health Services Domestically 18 Use United States Leadership to Advance Sexual and Reproductive Health Globally 24
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