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Abstract
Objectives Sexual health needs of young refugees and asylum-seeking men are seldom explored or addressed, adversely affecting their mental and physical well-being. By interviewing young male former unaccompanied minors, refugees and asylum seekers in Stockholm, Sweden, this study aimed to get a deeper understanding of what they needed to achieve a positive and respectful approach to sexuality, romantic and consensual relationships. Additionally, we explored how their sexual health needs were related to their mental health, as well as the factors influencing both.
Design An exploratory qualitative study using semi-structured interviews was employed. Theoretical sampling was used for participant selection. Analysis of the data was performed using constructivist grounded theory.
Setting The study took place in Stockholm, Sweden.
Participants A total of 32 young male (aged 16-28) former unaccompanied minors, asylum seekers and refugees from Afghanistan, Eritrea and Syria were interviewed.
Results Our analysis showed that our participants’ sexual and mental health needs followed a process of individual change. One core category described the different stages of the process: ‘On my way, but not there yet’. It contains four subcategories: ‘being on the move: the migration journey’; ‘newly arrived: contrasting old and new values and learning new concepts’; ‘navigating relationships, love and sex’; and ‘the respectful man’. We identified six key factors that influenced their sexual and mental health needs: attending school/receiving accurate sexual information, support to adapt, experiencing enjoyable relationships, restrictive parental values, exposure to stigma/discrimination and the negative image of young male refugees.
Conclusions This study highlighted that the sexual health needs and related mental health aspects of young former unaccompanied minors, asylum seekers and refugees change over time and are influenced by contextual factors. Educational interventions aiming to improve the well-being of this population must address both sexual and mental health aspects, including issues related to gender norms, relationships, sex and consent.
- Health Equity
- QUALITATIVE RESEARCH
- PUBLIC HEALTH
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
By using constructivist grounded theory, we were able to describe the process of change and the development of hybrid masculinities among our study population.
Data collection and analysis were performed concurrently with constant comparison between our data and codes, enhancing the credibility of our study.
Results cannot be transferable to young male refugees or asylum seekers outside of the nationalities included in this study.
Due to the sensitivity of discussing sexual and mental health topics, it is likely that some strong negative sexual experiences were not disclosed during the interviews.
Introduction
In the last 15 years, forced migration, being coerced to leave one’s country for various reasons including escaping from war, political, ethnic and/or religious prosecution,1 2 and prosecution based on sexual orientation and gender identity,3 has contributed to shaping the population dynamics in Europe and elsewhere.4 The number of asylum seekers and refugees arising from forced migration has increased globally, with 30.5 million refugees in 2020 and 1.04 million seeking asylum in the European Union (EU) in 2023.5 The same year, data on EU asylum seekers’ applications showed a clear gender and age pattern where 70% of all applicants were men and 25% were below 18 years of age, of which many were unaccompanied minors (UMs) on the move without parents or other family members.5 Young men (aged 18–34) represented 41.7% of the total number of male asylum seekers in the EU.5
In general, earlier research has consistently indicated that refugees and asylum seekers face social, cultural and legal barriers during their migration journey, and in the host countries.6–8 These barriers often lead to enhanced health risks and negative health outcomes,6 7 including poor sexual and mental health.7 9–11 Our paper focuses on the intersection between sexual and mental health as they often can catalyse each other, especially among young people.12–14 For example, a review conducted by Mhlongo et al found that poor mental health among young men, including men with refugee backgrounds was associated with previous exposure to sexual violence and several poor sexual health outcomes, including sexual dysfunction and higher sexual risk-taking.14
In this current study, sexual health is understood not only as the absence of disease but as people’s right to have voluntary, safe, respectful, consensual and pleasurable sexual relationships free from violence and discrimination.15 16 Achieving good sexual health, as defined above, implies that people have access to evidence-based comprehensive sexuality education,17 access to free and high-quality sexual health services,10 16 18 as well as having adopted equitable norms around gender, sexuality and partner relationships,16 through the realisation of one’s sexual rights.16 In Europe and Australia, young refugees, including individuals arriving as UMs, from low- and middle-income settings with limited or non-existent sexuality education, restricted access to sexual health services and inadequate sexual health awareness and knowledge had a notably increased risk of experiencing poor sexual health,19–23 resulting in unmet sexual health needs.11 24
Previous studies have shown that young refugees’ and UMs’ sexual health was further impaired by their heightened vulnerability to sexual violence, exploitation and human trafficking during their migration journeys7 11 25, as well as exposure to discrimination19 26 and social exclusion in the host country.27 While most young refugees probably perceive that navigating relationships is a vital part of one’s sexual and reproductive health,23 it can however be compromised by conflicting sexual and gender norms between those in their country of origin and those in the host country.20 For instance, an Australian review revealed that families holding on to ‘old values’ influenced how young refugees understood and constructed sexual health and relationships, including seeking sexual health information and exploring relationships.23 Furthermore, one study with young refugee men and women settled in the USA found that traditional family norms shaming sex before marriage and endorsing abstinence hindered refugee youth’s access to sexual health information.28
Our study follows the WHO’s definition of mental health, which highlights that it is more than the absence of diseases and focuses on people’s abilities to cope with stress in a healthy way, build relationships and make meaningful life decisions.29 Several studies have reported that the same factors harming young refugees’ and asylum seekers’ sexual health also could harm their mental health, contributing to a higher prevalence of mental ill-health30 and lower access to healthcare in this population.30 31 A systematic review with a global perspective found that the prevalence of mental ill-health among refugees and asylum seekers ranged from 31% for post-traumatic stress disorder and depression to 11% for anxiety.32 High levels of anxiety and depression were also found among newly arrived UMs in Europe.33
Few studies have focused on the association between refugees’ and asylum seekers’ opportunities to build meaningful relationships and mental health. A qualitative study in Germany showed that refugee men from Iran and Afghanistan faced numerous barriers to engage in reciprocal relationships, leading to isolation which harmed their mental health.34 Another qualitative study with Eritrean asylum-seeking men in Israel showed that challenges in establishing romantic relationships translated into mental distress, loneliness and sexual dissatisfaction.35
Rationale
Around 20% of the population in Sweden are foreign-born. In 2015, around 164 000 people sought asylum in the country, of which 70% were male and 22% were UMs.36 Most of the refugees and asylum seekers arriving in Sweden during 2015–2017 were boys and young men from Syria, Afghanistan and Eritrea.36
Given the enhanced vulnerability faced by many young refugees and asylum seekers, including UMs, several studies have been conducted in Sweden to identify the prevalence and risk factors for poor sexual or mental health.27 37–40 These studies have indicated that young people with refugee and migrant backgrounds have a higher prevalence of sexual and mental health problems than non-refugee youth.27 37–40 In addition, they are more likely to have lower sexual and mental health literacy and limited knowledge of where to seek help than the native population which often lead to a lower uptake of health services.38–41
Despite the significant body of research on young refugees’ and asylum seekers’ health conducted in Sweden, none of these studies have focused on exploring the link between sexual health needs and associated mental health aspects of young male former UMs, young refugees and asylum-seeking men and how these needs develop over time in a new country. Focusing on these young men is important since studies in Sweden and elsewhere have overwhelmingly focused on women39 and shown that young men with migration backgrounds have less access to sexual and reproductive health services,21 39 42 and tend to have poorer sexual health compared with their female counterparts.39 41 In addition, longitudinal data analysis involving young adults with a refugee background in the Nordic countries found that refugee men had a higher risk of mental health problems in Sweden and Denmark compared to native-born men, a pattern that was not found among refugee women.43
Our study aims to fill this knowledge gap by exploring the sexual health needs of young male Syrian, Afghan and Eritrean former UMs, who are currently refugees, and asylum seekers in Region Stockholm during 2019–2020, in terms of having a positive and respectful approach to sexuality, romantic relationships and consensual sexual relations. We also aimed to explore how the fulfilment (or lack thereof) of these needs was related to their mental health, as well as the factors that restricted and/or facilitated the fulfilment of those needs. The evidence generated by our study can be used by public health policymakers to continue improving programmes targeting this population.
Theoretical framework
We applied a gender lens to understand the sexual and mental health needs of our participants, since social constructions of masculinity influence how men identify and respond to stressors in their lives as well as their relationships with other men and women.44 For example, endorsement of traditional forms of masculinities has been associated with men’s higher sexual risk-taking, depression, suicide, and performing sexual violence, among other negative behaviours.45 46
Masculinities can be described as societal norms defining how men should behave.44 Connell proposes that there are different types of masculinities (hegemonic, subordinate, complicit and marginalised) being enacted and that they relate to each other through unequal power relations.47–49 Among these, hegemonic masculinity is defined as ‘the configuration of gender practice which embodies the currently accepted answer to the problem of the legitimacy of patriarchy, which guarantees the dominant position of men and the subordination of women’.47 Hegemonic masculinity varies across settings, but it represents the quintessential version of manhood in each society. Complicit masculinities do not seek to enact the hegemonic ideal but fail to reject the norms and practices legitimising patriarchy.47
Connell further describes that masculinity constructs intersect with men’s ethnicity and sexual orientation, resulting in marginalised and subordinated masculinities.47 These masculinities share privileges that gender provides to men unequally with hegemonic masculinity.47 We argue that the masculinities of refugees, asylum seekers as well as others with forced migration backgrounds are a form of marginalised masculinities, as they consist of an ethnically diverse group, often with a lower socioeconomic position with less power than other men in a given society.
Studies on men, masculinities and migration have found that men often experience a process of navigation, adaptation and change to new gendered expectations in the host country which can generate hybrid masculinities.49–54 Bridges and Pascoe define hybrid masculinities as ‘the selective incorporation of elements of identity typically associated with marginalized or subordinated masculinities into privileged men’s identities’.55 Although the term initially referred to hegemonic masculinity’s incorporation of marginalised or subordinated masculinities characteristics, Bridges and Pascoe clarify that this process can occur among marginalised masculinities as well.55
Method
Study setting
The study was conducted in Region Stockholm, the most populated region in Sweden with over 2.3 million inhabitants, of which 26.5% of the population are foreign-born.56 Between 2015 and 2020, the number of foreign-born young men aged 15–29 years increased, from 69 126 to 314 286, due to a higher influx of migrants, including asylum-seeking and refugee youths, with the majority being unaccompanied asylum seekers.57
In Sweden, universal healthcare is adopted and all health services, including sexual and mental health services and care, are governed by the regions and are largely publicly funded, even though privately-funded suppliers exist.58 Young asylum seekers under the age of 18 are entitled to the same health services and information as any Swedish citizen58 and have the right to attend school.59 On the other hand, asylum seekers over the age of 18 are not only entitled to emergency healthcare but to all health and dental care that cannot wait.58 60
Within the Stockholm region, sexual and mental health services and information for young people are provided at youth clinics (for young people aged 12–22), primary healthcare facilities, school-based services, and specialised clinics for sexual (for those over 23 years) and mental health.61–65 Youth clinics and specialised sexual health clinics offer testing and counselling about relationships, sexuality, sexually transmitted infections (STIs), contraceptives, and psychosocial issues.63 64
Compulsory sexuality education in Swedish schools was introduced in 1955.62 Sexuality education starts in primary school (grade four) covering topics such as puberty, sexuality and reproduction. It continues through high school, increasingly addressing more complex topics including, but not limited to prevention of STIs, gender norms, gender equality, sexual orientation and contraception.62
Sexual health information is also provided in various multilingual digital platforms by Region Stockholm and non-governmental organisations (NGOs).66–68 These platforms display information about sexual rights, sexuality, STIs, psychosocial health and where to find healthcare services among others.66–68 In terms of public health efforts, a linguistically and culturally-adjusted public health programme that addresses the sexual and mental health of newly arrived youth, including asylum seekers and refugees, is operated by the Transcultural Centre, which is Region Stockholm’s knowledge centre in migration, health and transcultural psychiatry.69
Study design and participant selection
A qualitative approach using semi-structured interviews was adopted. Eligible participants were young Syrian, Afghan and Eritrean refugee or asylum-seeking men living in Stockholm Region, between the ages of 15 and 29 years and who had been in Sweden for less than 10 years. These young men were chosen since they represented the majority of asylum-seeking and refugee young men arriving in Sweden in the last decade.36 56
Theoretical sampling was used to guide our sampling strategy70 as it allowed us to select our participants based on our evolving categories and their properties. The first set of interviews with young Afghan men were collected and constantly compared. This permitted us to develop initial categories and properties. We then proceeded to collect and analyse data from Syrian and Eritrean participants to compare their experiences with those of the Afghan participants. The variations found in the overall sample yield our final categories and properties by identifying the properties’ dimensions. Data was collected until saturation, which meant that no new properties were found in the data.70
Participants were identified by posting advertisements in schools, youth clinics, NGOs and youth associations working with migrant youth, including refugee and asylum-seeking populations. In addition, some of the initial participants also helped us to identify other potential participants from their communities. In total, data was collected from 32 participants (15 Afghans, 11 Syrians and 6 Eritreans). The participants’ ages ranged from 16 to 28 years. The majority came to Sweden as unaccompanied asylum-seeking minors (table 1), but six participants were later joined by family/close relatives. At the time of data collection, participants spontaneously reported their migration status. Of the 32 participants, 24 had been granted resident permits, five were granted refugee status (as they turned 18 years old during the application process or were young adults), and three were still in the asylum process, waiting for a final decision.
Characteristics of study participants (as self-reported)
The participants educational levels varied, with 28 attending or having completed high school and 4 attending university in Sweden. The number of years in Sweden ranged from 3 to 6 years, with the majority arriving in 2015. One participant self-identified as bisexual, and all others as heterosexual (table 1). During the interviews, the participants also revealed their marital/relationship status, with 22 being single (although most have had past relationships) and the rest reported having current partners. None of the participants were married or had children.
Data collection
Data collection and analysis were carried out in parallel with constant comparison between our data and our codes.71 This allowed us to incorporate topics mentioned by the participants that were not included in the original semi-structured interview guide, into the subsequent data collection. In addition, it permitted us to develop emerging hypotheses that were later tested with new data.
All data was collected between June 2019 and October 2020. The 32 semi- structued interviews were conducted in Dari, Arabic and Tigrinya, using a semi-structured interview guide. Most of the interviews took place face-to-face at Karolinska Institutet or at one of the NGOs in private rooms to ensure confidentiality. Due to the COVID-pandemic restrictions, four of the interviews in Tigrinya were conducted via Zoom. All interviews were audio-recorded and lasted between 1 and 2 hours.
The data was collected by two trained research assistants who shared the same mother tongue as the participants but were not known to them. The research assistants were extensively trained in qualitative data collection methods, including how to conduct the interviews with empathy, respect and confidentiality. Either the first or the last author also participated in the initial seven interviews conducted in Dari and four conducted in Arabic, to confirm that the data was collected properly (ie, follow-up questions used, ethical procedures). The first author collected all interviews in Tigrinya.
Interview guide
A semi-structured interview guide was constructed based on a literature review and in consultation with sexual and mental health experts. The interview guide discussed the following topics: (1) the migration journey to Sweden, (2) experiences of living in Sweden versus their home countries, (3) perceived similarities and differences in relation to gender norms, sexual consent and access to sexuality education/information between both settings, (4) perceptions and experiences of partner and sexual relationships in Sweden and in their home countries and (5) experiences of living in Sweden and how it relates to their sexual and mental health. To determine attitudes, norms and behavioural changes among the participants, we asked them to compare and describe any changes that have occurred post migration, by, for example, using questions such as: ‘Can you give an example of how you would approach someone you are attracted to before coming to Sweden, and now when you are in Sweden?’ and ‘If you compare your experiences, what would you say are the differences and similarities?’. Open-ended, probing and follow-up questions and a vignette were used to get a deeper understanding of the participants’ experiences.71 72 See the interview guide in online supplemental file 1.
Supplemental material
Data analysis
Analysis of the data was conducted by using constructivist grounded theory.71 First, line-by-line open coding was performed to summarise the data. At this stage, coding was close to the data and was made without predefined codes. Coding was carried out by searching for, but not limited to actions, emotions, consequences, in-vivo codes, values, attitudes, circumstances, etc, in the text.
The second stage was focused coding, by which codes were clustered into subcategories. From this, a core category emerged. As the third step, axial coding was performed to detect the link between the subcategories, as well as, their properties and dimensions.71 In the fourth step, theoretical coding was used, enabling us to identify the relationship between the core category and the factors facilitating or hindering the core category, and ultimately creating a visual model representing these relationships (figure 1).
‘On my way, but not there yet’. The process of change, its associated sexual and mental health aspectsand the factors influencing the process. LGBTQ, lesbian, gay, bisexual, transgender and queer.
Memo writing was used throughout the data collection and analytical process, to record emerging ideas and hypotheses from the data. It was also used to detect gaps, and thus the need to include further questions and/or participants in the data collection process.71 OpenCode 3.6 software was used to facilitate coding.73
Trustworthiness
Several strategies were used to improve the trustworthiness of our results.74 During data collection follow-up, probing and interpreting questions, as well as a vignette75 were used to stimulate discussion and clarify our developing hypotheses. The codes, categories and model were thoroughly discussed between the authors with different professional backgrounds (sociology, public health and medicine), enabling exploration of the data from different perspectives (researchers’ triangulation). Peer debriefing with other researchers and practitioners provided outside feedback into the research process. The transferability of our findings was enhanced by a rich description of the setting, leaving the readers to evaluate if the results are applicable to similar settings.74
Reflexivity
Within the research team, we discussed our views and experiences prior to and during data collection and analysis, to reflect on how it may have influenced our interpretations. Reflexive practices were used for this purpose, by field journaling, exploration and confronting assumptions72 of what sexual health, relationships and gender norms and equality meant for our study participants. The first author, a female researcher, and a public health professional with a migration background was present in many of the interviews and solely conducted all the interviews in Tigrinya. This may ultimately have influenced how the young male participants approached and answered some of the questions and expressed their gender identity. However, having prior professional experience in sexual and mental health among young asylum seekers and refugees (including young men), experience conducting qualitative research in cross-cultural contexts, as well as having spent time in the field may be considered as an advantage. The last author, a male researcher, has a background in masculinity studies which influenced the choice of the theoretical framework used in this paper. The other coauthors' backgrounds in global health and research with vulnerable populations allowed an interpretation of the data from multiple perspectives.
Being an insider-outsider has a variety of influences in terms of how cultural competence and language abilities enabled a deep understanding of the participants’ experiences. Therefore, it is hard to know how the research assistants and researchers may have influenced the interviews, analysis, and the research process.72
Ethical considerations
According to Swedish law, children aged 15 years and above, can participate in a study without parental/guardian consent (The Ethical Review Act, §18-Lag (2003:460)).76 Thus, the Swedish Ethical Review Authority approved our process of obtaining informed consent. Written informed consent was obtained from all participants prior to data collection, describing the study objectives and procedures, ethical principles, possible risks and how confidentiality was protected. Participation was voluntary and all participants were informed that they could withdraw from the study at any time. Information on how to contact the principal investigator for questions and clarifications was also provided.
During the interviews, follow-up questions were asked to ensure that participants understood the posed questions and if further clarification was needed. The likelihood that research participants experienced any kind of harm (psychological, social, legal, economic or environmental) was low. However, some young men may experience discomfort when talking about their experiences, since it can evoke feelings of distress. To address this, researchers and research assistants were trained in how to provide emotional support and/or refer to appropriate health services if needed. None of the participants needed to be referred. At the end of each interview, all participants received a list of contact information for mental and sexual health services in their communities. Data were anonymised before analysis by giving each participant a code number. The transcripts were saved in a secure server, where only the last author had access to the files. Two movie tickets were provided as an incentive for participation.
Patient and public involvement
Patients and/or the public were involved in the design, conduct, reporting and/or dissemination of this study.
Results
Our analysis showed that our participants’ sexual health needs and associated mental health aspects followed a process of individual change as they adapted to the Swedish society. The core category represented this process of change: ‘On my way, but not there yet’ (figure 1). It contains four subcategories: ‘being on the move: the migration journey’; ‘newly arrived: contrasting old and new values and learning new concepts’; ‘navigating relationships, love and sex’; and ‘the respectful man’ that describe the different stages of the process and its associated sexual and mental health aspects. We also describe the factors facilitating and hindering the process, as well as the properties and dimensions of the core category (table 2). We show the properties and dimensions according to the subcategory where they were first identified; however, it is key to highlight that they run across the core category. In the following, we describe each subcategory sequentially.
Properties and dimensions of the core category* ‘On my way, but not there yet’
Subcategory 1: being on the move – the migration journey
Duration, circumstances and conditions of the migration journey varied among the participants, which permitted us to identify the first property ‘conditions of the migration journey’. The dimension of this property represents the journey being relatively safe to perilous in extreme. For the latter, the dangers faced included passing several borders, unsafe boat trips through the Mediterranean Sea, being treated poorly by smugglers or police, experiencing hunger, imprisonment, and witnessing people being sexually violated, and even killed. The young men described mental health challenges such as feeling overwhelmed, distressed, lonely, displaced, anxious and depressed when arriving in Sweden. In addition to the above, those participants reporting on a perilous trip also experienced nightmares, headaches and insomnia.
My trip to Sweden was very long and tedious. It was very disappointing. Also, I could not focus on anything in my daily life due to bad memories from those countries. I had nightmares…I could not sleep…this put me under mental pressure and caused me headaches. (Afghan young man)
Subcategory 2: newly arrived – contrasting old and new values and learning new concepts
As newly arrived in Sweden, the participants experienced challenges such as separation from family/partner, being placed in crowded refugee settlements and a long asylum process, for some still ongoing. Migration status and related psychological health issues made it difficult to focus on romantic relationships and one’s sexual health, initially as newly arrived individuals. For one participant, it was expressed as decreased sexual desires.
Since I came here [Sweden], I felt depressed and frustrated… I didn’t know anybody here, I just wanted at least someone to talk to….so I avoided sexual experiences…I didn’t want [sexual relationships] and cared about that anymore. (Syrian young man)
Our participants discussed that arriving in Sweden allowed them to feel more secure, free and independent. However, they also described experiencing a clash between cultural norms in their country of origin and those prevailing in Sweden, especially those around gender equality and sexuality. During this time, the mental health challenges that the participants carried from their journey to Sweden were compounded by their uncertainties, anxiety and stress due to clashing cultural norms. For example, participants reported that in some cases, it was their first time witnessing and experiencing a society where people could freely have premarital contact with the opposite sex, including hugging and kissing in public. A reflection among those coming from deeply religious settings was that they felt less restricted in how the practice of their religion influenced their sexuality, sexual practices, choice of partners and how they formed friendships.
Now, the first thing I noticed here was gender interactions, certainly as friends, that it is normal for you to have friends, girls, and boys, at the same time, it isn’t considered wrong here… The other thing I noticed was people kissing in front of me, and I realized that this was normal… in the beginning, it seemed a little bit weird because I haven’t seen something like this before, it was more like a shock…and later I discovered how the society works here, so it makes things easier. (Syrian young man)
Another example of contradictory norms was related to women’s autonomy. The participants reflected that in their home countries, women were viewed as submissive, had limited autonomy, and in some settings, they were limited in terms of working outside the home or having male friends. In contrast, they reflected that women in Sweden have significantly more autonomy and freedom. The young men reported that they have become more mindful of this normative change due to their interaction with peers at school and contact with local NGOs and youth clinics among other sources. This allowed us to identify the emergence of the second property of the process which we named ‘awareness’. The dimension of this property represents the transition between being unaware to being mindful of the prevailing gender norms in Sweden, a property that continued to develop as the process of change moved forward. One participant commented:
The school and classes I attended have had a real impact on my mindset…I have obtained new information on sex, sexuality…I learned that men and women have equal rights… it didn’t happen overnight. But it affected me a lot. (Afghan young man)
Nonetheless, they also mentioned resistance and negative reactions given by some during sexuality education sessions in school. Participants described witnessing young men and women with migration backgrounds becoming discontent, upset and leaving these sessions, while others laughed, felt frustrated or uncomfortable discussing such topics.
As they spent more time in Sweden, a common view among the participants was that they started adjusting, embracing a new mindset and a new way of living. The shift was explained by acquiring new experiences and getting older. The change was considered inevitable and happened gradually:
Sweden has changed me…but it was a process. It’s not how I expected it to be…one needs to accept it and think differently about things to adapt… and be open to new experiences, it’s difficult in the beginning but it happens with time. (Eritrean young man)
Subcategory 3: navigating relationships, love and sex
Although enjoyable relationships were said to be positive experiences, engaging in and navigating love, friendships, and sexual relationships were described as challenging, stressfuland disappointing due to different reasons. For instance, our participants migrated from countries where interaction between the sexes was limited and highly regulated. In one setting, breaking these cultural norms carried severe consequences including violence and imprisonment. Even though in Sweden these norms did not apply, they had a lingering effect on the young men’s ability to interact with young women. In addition, their perception of romantic relationships was often tied to long-term commitments and/or marriage, an expectation that was often not shared by their partners.
I couldn’t dare to talk to girls because that is how I was brought up…that’s how the society is there. If you decide at a certain age to have a relationship with a woman, it’s supposed to be a long term one …you are supposed to get married. (Syrian young man)
In the previous phase, our participants started to become more mindful of gender equality norms in Sweden; however, this process of acceptance was still ongoing. Challenges emerged when they started to engage in romantic relationships. While participants reported dating both Swedish and non-Swedish partners, some preferred dating partners from their own ethnicity who were perceived to share the same values around women’s roles in a couple. Nevertheless, this was not always the case as it was discussed, particularly among Eritrean young men, that potential partners from their own ethnicity have already ‘embraced’ Swedish empowering values. This was described as very worrying and frustrating.
If you do not listen to them and do as they want, they would say that…Several girls have told me “You are in the land of women now” [referring to Sweden]. (Eritrean young man)
Challenges also emerged when our participants discussed the possibility of having sex. Participants discussed that in their home countries, religious beliefs forbid sex before marriage and parents often stressed that premarital sex was not allowed. In the past, young men believed it to be a sin and felt guilty and anxious when engaging in sexual relations. Now, living in Sweden, most were less limited by religious restrictions and beliefs, particularly regarding sex before marriage, as most participants no longer abstained from sex. This allowed us to identify the third property of the process which we named ‘openness to sex’. The dimension of this property represents the transition from feeling constrained to being more relaxed and open to engage in sexual relationships before marriage. For our bisexual participant, however, accepting his sexuality and having sex with other men was still considered challenging. He discussed experiencing anxiety, anger, disappointment and self-disgust.
Those who had never approached young women prior to coming to Sweden disclosed feeling more confident at this time. They were also more comfortable being on online dating applications, revealing their true origin, regardless of fear of judgement and rejection. For most participants, a young woman’s/man’s background and religious conviction were no longer as relevant for initiating a relationship. During their time in Sweden, they have interacted with women from diverse cultures.
I have changed here. Before they told me that it’s taboo and forbidden to talk to girls… now I can talk to and approach girls, it doesn’t matter where they come from, and it doesn’t matter if they know I’m Afghan. (Afghan young man)
Despite having more experience and self-confidence with young women, some participants disclosed still lacking sufficent practical experience and knowledge in approaching, interacting and maintaining a meaningful long-term romantic and sexual relationship with a potential partner. Recognising their lack of knowledge and skills, the young men felt upset, irritable and/or useless with low self-esteem.
Subcategory 4: the respectful man
Respectfulness is a key property that was identified in this subcategory. The dimension of this property represented the participants’ transition from being less to more supportive of women’s sexual autonomy (including consent for sex), gender equality and individuals belonging to the lesbian, gay, bisexual, transgender and queer (LGBTQ) community. The transition described above was exemplified by their evolving views on sexuality and sexual consent. They reflected that in their home countries, a husband can claim sex as his right and a wife should not deny her husband sex. However, they described that their experiences of living in Sweden allowed them to recognise that sexual consent must be mutual, and one must respect and accept women’s desires and needs.
Here in Sweden, it is more important to have mutual consent (for sex) and that is done through communication. People ask here if they want sex, if they are ok with it, it happens, if not it doesn’t happen. (Afghan young man)
Our participants also reflected on the difficulties of communicating and understanding sexual consent and the factors shaping it in Sweden. They described that it can be easy to misunderstand a partner’s non-verbal signs and clues especially if the person is indecisive, tired, drunk or stressed, resulting in some participants feeling uncertainty-related stress. Despite the development described above, some traditional views persisted. In some cases, women who were seen initiating sexual contact and clearly expressing their desires were perceived as promiscuous.
I changed my feelings towards her, we wanted to be in a relationship, but after she did that, everything changed. I found out that she was an easy girl [she wanted to have sex]. (Syrian young man)
They described an attitudinal shift from their initial own patriarchal understanding of society and gender relations to a more open stance on and support of gender equality. They viewed Sweden as a setting where women and men had equal rights. There was strong agreement that women in Sweden were independent and often respected, and that they have rights and express their opinions openly. Women’s freedom was voiced in how they dress, act, talk and in their appearance, where women can dress very revealingly. In contrast to their home countries, women in Sweden also smoked and drank alcohol. This facilitated their exploration of, and engagement in romantic and/or sexual relationships, but at the same time, it also brought further sexual - and related mental health challenges.
The participants’ understanding of manhood was described to have evolved towards a more respectful perspective towards others (women and the LGBTQ community), less use of violence for solving conflicts, more involvement in household tasks and acquiring a more caring attitude towards their future children.
Men and women are equal here [referring to Sweden] …My views on men have changed. Before, I had the view of a man as in Eritrea. Here, men and women work together, and I believe that men should be able to do everything either inside or outside the house and should help their wives (Eritrean young man)
Key facilitating and constraining factors of the process
We identified six key factors that influenced the sexual and mental health of the participants (figure 1): attending school/receiving accurate sexual information, support to adapt, experiencing enjoyable relationships, restrictive parental values, exposure to stigma/discrimination and negative image/narrative of young male refugees. For example, those who described coming to Sweden and later being joined by conservative parents stated that, despite being in an open society, they felt limited to express and freely explore romantic and sexual relationships. This led many young men to feel angry and frustrated.
It’s not possible for me…I have a family here [referring to his mother and siblings] …one should not have contact with someone before getting married, so I cannot have relationships like that here…my mother does not believe in the girls here [in Sweden]. (Afghan young man)
Although not all participants received sexuality education in Sweden, they highlighted the significance of accessing such intervention, particularly in schools, to develop sexual health awareness and knowledge. The young men stressed the importance of continuously discussing and reflecting on these topics as young asylum seekers and refugee men in Sweden. They believed sexuality education should be offered to all young refugees and migrants since most are not aware of where to obtain accurate information and education and how to talk about sex, sexuality and relationships.
Young people that come here from Eritrea don’t openly share about sexual health matters, and they don’t know where to find such information here…this kind of education is good for all young people. (Eritrean young man)
While receiving support to adapt and experiencing enjoyable relationships helped the young men to cope, navigate challenges in a new setting and build self-confidence, our participants described how perceived discrimination based on ethnicity, religion and language skills influenced their mental and sexual health. It was discussed how the negative narrative displayed by the Swedish media of young refugee men seemed to impact all aspects of their lives, specifically when forming and maintaining friendships, relationships and social networks. One participant said:
Afghans have a bad reputation here in Sweden …no one wants to be with you…the picture you get from media about Afghans is not correct (Afghan young man)
Other participants described that potential partners were often concerned about their backgrounds, language skills and lifestyles. They felt rejected and humiliated due to their ethnicity/country of origin. Rejection of these young men also occurred in different dating applications. They experienced being ridiculed, laughed at and blocked when revealing their identity.
Perceived disapproval or rejection by the parents of potential partners often resulted in feelings of disappointment, distress, anger and frustration. The participants felt that they were mainly rejected due to their religious affiliation or ethnicity. One Syrian participant decided to end his relationship based on religious differences.
My family is Muslim, and her family is Christian, so it will not work between us. Her family would not accept me. I think religion might affect the relationship somehow and that caused me depression, I was very annoyed because I used to love that girl. (Syrian young man)
Discussion
Our main results showed that our participants’ sexual health needs, and mental health aspects related to those needs, developed alongside an ongoing process of change. This process of change was facilitated by their interaction with the Swedish society and school settings and hindered by perceived societal discrimination and experiencing restrictive parental values.
Our participants’ process of adaptation was reflected in their attitudinal shift towards a more supportive stance towards gender equality in romantic relationships, women’s sexual autonomy and respecting the LGBTQ community. The description of these changes as a process is in line with what Penninx and Garcés-Mascareñas77 describe as integration, ‘the process of becoming an accepted part of society’ and the term ‘process’ has also been used by Thorpe and Wheaton54 to describe Gazan young refugee men’s actions and strategies to adapt to the Swedish society.
The process of change described in our data is by no means completed but is a process where our participants experienced a conflict between traditional gender and sexual norms in their home countries and the pro-gender equality norms in Sweden. Similarly, findings from other recent qualitative studies with young unaccompanied refugee men living in Sweden38 51 showed this cultural clash. As reported by others, post-migration understanding, experience and construction of gender, sexual and cultural norms among youths with migration backgrounds are influenced by how they carry former norms and navigate new ones in the host country.78 Thus, understanding our participants’ process of change was key to identifying how their sexual health needs were met and developed over time, as well as, how it shaped their mental health. In the following, we explain how both are linked.
Our data showed that as newly arrived in Sweden, our participants’ mental health needs prevailed over their sexual health needs. This is consistent with other studies showing that post-migration mental-ill health among this group is common and includes depression, anxiety and post-traumatic stress among other disorders.7 9 37 79 This finding doesn’t mean that there were no sexual health problems, but they paled when compared with mental health issues and their concerns about their resettling process as has been shown elsewhere.38 Another possible explanation is that their mental health problems at this stage affected their sexual life in terms of impaired desire, arousal, or sexual satisfaction,80 as also described in our data.
As our participants emerged from the initial post-arrival phase and interacted more with the Swedish society, they described a clash between the prevailing gender and sexual norms in Sweden and the norms from their home countries. These clashing norms made it difficult to navigate romantic and sexual relationships, adding a new source of stress and anguish to their poor mental health and limited their ability to have pleasurable sexual relationships. For example, lack of awareness around norms and feeling restricted from exploring romantic and sexual relationships had participants feeling anxious, angry and frustrated. This is consistent with other research that suggests that the experience of adapting to different gender and sexual norms and behaviours can be very stressful for young people and can result in poor sexual health.20 22 38 Our findings also mirror the results of previous Swedish studies conducted both with unaccompanied male minors38 51 and parents of refugee youth81 describing this normative clash and its negative consequences for young men’s sexual and mental health.
Nonetheless, our participants also described how their knowledge of and mindfulness of these new gender norms evolved over time into a new mindset, a more tolerant and greater understanding of gender equality. This ongoing transition was described in our results through the ‘awareness’ property of the process of change. The process of becoming more mindful of prevailing norms and sexual health matters, as well as confronting limitations and misconceptions, facilitated the transition to becoming more open towards closely interacting with the opposite sex and pre-marital sex. This is important since previous research has stated that relationships with others are pivotal for refugee youths’ well-being, sense of belonging, support and adjusting to a new cultural setting.82
‘Respectfulness’ emerged as the last property of the process of change. This property involves participants transitioning from being less to more supportive of women’s sexual autonomy, sexual consent, gender equality and individuals belonging to the LGBTQ community. Our findings about acceptance of the LGBTQ community among our participants are similar to the findings reported by Ingvars in a study of refugees in Greece.52 The increased awareness about consent for sexual relations is particularly important not only for our study participants but for young people in general. Our findings are in line with results from a European multicountry project showing that young people in general find discussing and communicating consent for sex difficult and this miscommunication can lead to ‘gray zones’ where sexual violence can occur.83
These are key findings showing that gender normative change is possible among this population and is in agreement with Connell’s gender theory arguing that gender norms change over time.84 85 It could be argued that this process of change also represents the construction of a new hybrid masculinity(ies) that incorporates norms and behaviours from both their home and host countries, as has been described by others.48 51–54 It is also possible that the development of these hybrid masculinities was a consequence of the rapid changes in our participants’ social, cultural and economic environment, as has been proposed by Inhorn.86 Thus, interventions aiming to foster UMs and young refugees’ mental and sexual health must include in-depth discussions on gender-equal norms, tolerance and respectful relationships. Nevertheless, it is important to highlight that those normative changes described above are an ongoing process, where some negative perceptions about women’s sexual agency persisted, thus showing the need for continued education and discussions about gender norms, sexuality and relationships with this population.
Facilitating and constraining factors of the process
Sexuality education in schools was described as a key factor facilitating the process of change described above, which lessened the impact that the participants’ cultural clash had on their mental and sexual health. This is in line with other qualitative studies conducted with refugee youth in Sweden and Australia.22 38 87 88 The need for sexual information and education that focuses on healthy relationships has been found in other studies among young people in Sweden regardless of their country of origin.89
In Europe, young refugees define good sexual health as being able to exercise their agency and have enough knowledge on sexual and reproductive health topics.90 In our data, parental or family pressure on our participants’ sexuality was a factor negatively influencing their sexual and mental health. This is in line with the findings of other studies in Sweden.39 For example, a quantitative study reported that 37.5% of young migrants in Sweden felt that they were restricted in whom to date, of which 12.7% were restricted by family members or fellow countrymen.39 Thus, for those joined (or later joined) by family members/relatives, interventions aiming to improve sexual and mental health should include actions to educate parents/other caregivers as well as diminish the risk of intergenerational conflict.81 87 For UMs, this may not be possible; however, we believe it is crucial for them to be enrolled in school and other interventions promoting sexual and mental health.
Refugees are subjected to discrimination on various levels, and the connection between perceived discrimination and poor health has been found in earlier studies to be strong.91 In our study, experiencing stigma/discrimination (from peers, potential partners and their families) was found and it provided challenges when forming relationships and a social network, which ultimately affected their sexual and mental health negatively. The negative narrative portrayed by the media, in particular during discussions around sexual violence, gender equality and refugee men in Swedish media, has played an important role in the development of attitudes towards refugees, especially after the migration crises in 2014–2015, when most of our participants arrived in Sweden.79 92 Research on the subject has shown that discrimination or ‘othering’ experienced by refugees in host countries has serious public health implications, contributing to the development of mental health issues, including chronic stress, anxiety, sleep disorders and depression.91
Needs and how to address the needs
To improve health equity among young refugees and asylum seekers (accompanied or unaccompanied), efforts targeting this group should include elements of social, mental and existential well-being, including how to build healthy relationships.82 However, longitudinal studies that follow the progression of needs and health of refugees are insufficient.91
Overall, our results show that evolving sexual health needs throughout the process involve support, knowledge development and guidance in relation to navigating cross-cultural gender and sexual norms, relationships, sex and communication, that are affected by masculinities and other power structures.88 To facilitate the change and develop their skills, in addition to support, guidance and educational interventions, opportunities for continuous reflection throughout the process are needed. This has important implications for developing timely and culturally appropriate educational material and delivering programmes that consider the evolving sexual and mental health needs of this population.39
Interventions are suggested to include and deal with migration-related health concerns to improve sexual and mental health literacy and agency.87 88 A participatory approach resulting in the co-creation of interventions/programmes where refugees/migrants are involved is recommended.93 For such efforts to be effective, competence is needed in terms of sexual and reproductive health and rights, intercultural communication and understanding of the underlying determinants of migrants’ health.87 88 Based on the findings from this study, we, together with the staff at the Public Health Unit, Transcultural Centre at Region Stockholm have co-designed an educational intervention, to address the sexual and mental health needs of refugee youths and unaccompanied asylum-seeking minors.
Conclusion
This study highlighted that sexual health needs and related mental health aspects of our study population change over time, including attitudinal changes. The findings also illustrate the importance of understanding the factors influencing the process of change. Educational interventions aiming to improve the well-being of this population must address both sexual and mental health aspects, including issues related to gender norms, relationships, sex and consent.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
The study obtained ethical clearance from the Swedish Ethical Review Authority, Dnr: 2019-01159. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We are grateful to all participants who participated in the interviews, to the professionals at RFSU (Swedish Association for Sexuality Education) and the Knowledge Centre for Sexual Health at Region Stockholm for providing feedback in terms of the interview guide. We also would like to thank the non-governmental organisations, schools and youth associations for helping with recruiting participants, and Sofie Bäärnhielm, Carla Sturm and Maria Sundvall for proofreading and providing feedback.
References
Footnotes
Contributors JTM contributed to the initiation of the study and study design, coordinated data collection, conducted data analysis, interpretation of the results and drafting of the manuscript. MS is the guarantor. MS initiated the study and was responsible for study design and methodology choices. He contributed to drafting the interview guide, data collection, trained research assistants, interpretations of results and drafting of the manuscript. BF and ML contributed to data collection and transcribing the interviews. AME contributed to initiating the study and revising the manuscript. JTM, MS and AME made contributions to critically revising the manuscript. All authors approved of its final version.
Funding This study was supported by Region Stockholm (Stockholm County Council) (Grant number 232100-0016). Open access funding was provided by Karolinska Institutet.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.