1. Malin Lindroth RN, PhD-student Health & Society Faculty of Health and Society Malmö University

2.  Background  Results from survey + interview study  A sex education curriculum  Your questions and comments

3.  To gain knowledge about sexual health among youths at special residential homes  To develop a sex education curriculum targeted at these youths, and to let detainees reflect upon it.  Strengthen sexual health

4.  Sexual health – What?, Why?  Sex education – What?, Why?

5. Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.

6.  WHO & WAS: youths have a right to sex education  Legislated in Sweden (School Law) since 1956  Latest version of the law (2011) advocates a sex education promoting sexual health

7.  Always situated in a social and historical context, not a natural phenomenon  Not static but dynamic  A rights-based perspective (to chosen sexuality and to knowledge)

8.  An understudied area  Poorer sexual health  Elevated sexual risk-taking and exposure  Youths wish to discuss and learn more

9.  Youths at residential homes have many questions and concerns about sexuality

10.  Experiences?  Attitudes (to sexuality, parenthood, and sexually transmitted infections etc.)?  Differences girls-boys?, detained youths- same aged peers?

11.  148 (53 girls, 95 boys) from 22/27 residential homes  15-20 years (mean age 17)  84 % born in Sweden, 44 % at least one parent born outside of Sweden  Ethical exclusion criteria  Internet-based survey

12. Detainees (N=144) % Non-detainees (N=5940) % Sex Males/Females 64/ 36 44/ 56 Age 15-17/18-20 58/ 42 35/ 65 Immigrant status No/1 st or 2 nd generation immigrant 53/ 47 82/ 18 Early sexual initiation (< 15 years) No/Yes 22/ 78 69/ 31 Unprotected vaginal/anal intercourse last sex No/Yes 50/ 50 79/ 21 Alcohol consumption before last sex No/Yes 56/ 44 77/ 23 Drug use before last sex No/Yes 68/ 32 97/ 3 Number of sex partners last year 6 78/ 22 91/ 9

13. Detainees (N=144) % Non- detainees (N=5940) % Ever given reimbursement for sex No/Yes 91/ 9 98/ 2 Ever received reimbursement for sex No/Yes 91/ 9 98/ 2 Ever sex against one’s will No/Yes 38/ 62 53/ 47 Knowledge of Chlamydia Low/High 58/ 42 35/ 65 Considered risk for Chlamydia High/Low 13/ 87 9/ 91 Considered severity of Chlamydia High/Low 54/ 46 64/ 36

14. Detainees (N=144) % Non-detainees (N=5940) % Ever pregnancy No/Yes 60/ 40 86/ 14 Ever Chlamydia No/Yes 86/ 14 92/ 8

15.  Elevated sexual risk-taking + exposure + adverse sexual health outcomes is more common among youths at residential homes (See Lindroth, Tikkanen & Löfgren-Mårtenson, Scandinavian Journal of Public Health, 2013)

16.  20 (9 girls, 11 boys), 15–20 years  Half born in Sweden as their parents  Truancy, running away from home, substance abuse, criminality  Majority stayed at a residential home before

17. Well, I have one now, a fuckbuddy, and I have another that I talk to, see, someone I try to make into, to fix a relationship with. And I always have another one on the side. It’s like a car, you always keep a spare tire in the trunk. That’s how it works in my world; you always keep a spare girl. Get it? (Boy, 17)

18. You know, I’ve never wanted a child. I think it’s creepy with the belly and all. Plus, I’m not mature enough. And if I’d have it, the social services would take it from me, and I don’t want that to happen. I want to be able to…. I want my child to grow up safe. I want a lot of money, a good guy, an apartment and a job, things like that. You’re supposed to take care of yourself before you take care of a child. (Girl, 16)

19. Cause I was with a guy who was very decisive. He wanted…he forced himself upon me a lot of times. We were together for about nine months and, well, sometimes he used the condom and sometimes not. That’s what happened. Otherwise I wouldn’t have done it without. (Girl, 15)

20. They surely don’t feel good. You know, I think of those, those people who use others in that sense, rape and force others. They are the kinds who have been through things like that themselves when they were kids. (Girl, 15)

21.  Sex/gender, age, substance abuse, low school attendance, search for assurance I’ve never felt forced to do it. Sure, I’ve had sex with all my male friends. That’s how we are. And they give, usually give drugs to me, most of the time. They are a lot older than me. But I´ve never felt like, everyone else sees it like, ‘but, they are with you because they get sex from you’. But, if I say no, it’s no, and they respect that. I get drugs from them anyway. (Girl, 17)

22.  Expectations within the group They said, “She, that chick wants you, go get her now”, and I, “No man, fuck it”, and they, “Why don’t you just do it?” No, I didn’t have the energy for it. I’ve had other stuff to do, things I care about, you know, I wasn’t up for it. (Boy, 19)

23.  Belonging to a class in society with limited access to knowledge and skills needed in order to avoid sexual risks You know, school, it’s not my thing. I’m streetwise….To be honest, I haven’t learnt much about sex.(Boy, 19)

24.  The possibility of a chance for something good (pleasure, comfort, status etc.) outweighs the risk of something bad (STI, unwanted pregnancy) (See Lindroth & Löfgren-Mårtenson,The European Journal of Contraception and Reproductive Health Care, 2013)

25.  Most Swedish adolescents receive sexuality education.  About 70% say they now how to avoid unwanted pregnancy, 50% how to avoid an STI.  Relationships more important than “biological facts”  Important to adjust sex education to group It doesn’t matter as long as it’s not one of those stuck-up geeks. It should be someone self-confident; otherwise, you feel ‘well, well, the teacher got embarrassed’, or something like that.(Girl, 16)

26.  Experiences of, and demands on a sex education?  Reflections upon a suggested curriculum?

27. Session contentMain issues to discuss 1 Body development, anatomy What is puberty? Female and male anatomy, how do the genitals work? 2 Body image, self-esteem What is an ideal body and why? What is self-esteem is it related to sex? 3 Gender roles, hetero normalcy, sexualities What is female/femininity, what is male/masculinity, why? What is hetero normalcy? What is homo, bi, trans, hetero, asexual? What are Sexual and Reproductive Health and Rights, SRHR? Does SRHR vary in different cultures or contexts? 4 Relations Watch the film “Sex on the map” and discuss it. 5 Contraception, pregnancy, abortion, parenthood What are the advantages and disadvantages of different contraceptive methods? Menstruation, conception, pregnancy, birth and abortion, how does it work? 6 STI How do you contract, discover, seek help, cure and protect yourself from different STI? 7 Selling/buying sex, pornography, sexual abuse What does the law say on selling/buying sex, are there any grey zones? What is and where is pornography? What is sexual abuse, what does the law say? 8 Alcohol, drugs and sex What does the law say? What are the advantages and disadvantages of alcohol and/or drugs and sex? 9 Sexual desire, sex on your own, sex with others What is sexual desire? Read the booklet “Sex my way”. 10 Self-determination, the Internet How to say yes, or no, to sex? How can the Internet be a (sexual) resource?

28.  4 groups  14 adolescents (7 girls, 7 boys)  14-19 years

29.  Appreciate the curriculum content  Pedagogics (dialogic and norm critical) may facilitate  Reflections on adjustments (previous experiences, current situation)

30. “We’re not even allowed to talk about drugs here” (Boy2FG1) “No, I can imagine that” (ML) “The staff, they just: noooooooo” (Boy4FG1) “But I think it´s important to talk about alcohol and drugs, how does alcohol for instance affect feelings, and sex and how….” (ML) “I can´t have sex when I´m drunk” (Boy2FG1) “….how does drugs affect feelings and sex? Are there pros to be drunk or stoned when you have sex, are there cons?” (ML)

31. “When I´m drunk I can have sex for hours, it’s sick really” (Boy5FG1) “And I can’t get it up” (Boy2FG1) “I lost my virginity when I was drunk; I had sex for two and half hours” (Boy5FG1) “I also lost it when I was pissed” (Boy1FG1) “But, it can also feel really bad. I know that if I take ‘lad’ and Viagra, if I mix it….(Boy4FG1)

32. -“Lad?” (ML) -“Yeah, coke you know, then you feel like a porn star, you are, you get totally fucked up”(Boy4FG1) “Pump up some X and do your thing” (Boy3FG1) “Yeah, and then, if you do it a couple of times, if you do it with the same chick, at parties and so….then it feels so boring when you don’t do it (with drugs), you feel so deprived when you have sex. Like, what the hell is this? It feels like you´ve had the best experience and then, when you do it clean it´s just so boring” (Boy4FG1)

33. ” But, I was 14 the first time they took me of the street” (G3FG2) “I see, then it was probably because you were 14” (ML) “But there is no law prohibiting one from selling sex!” (G3FG2) “No, no there isn´t. But it was probably because you were under 15” (ML) “Uhu, yeah, maybe” (G3FG2)

34. “What would be not so good about it then, can you think of something?” (ML) “You might get sad and you might get, you might get affected.” (G3FG2) “You mean reminded of things you don’t want to think about?” (ML) “Mmmm.” (G3FG2) “Do you still think it’s important to discuss these things or is it too tough?” (LC) “Maybe tough talking about, but….”(G2FG2) “You don’t have to go deep into stuff (G3FG2)

35.  Youths at Swedish residential homes appear more risk-taking and sexually exposed than their same aged peers  Timing (earlier) and setting (more risky) differs  However: The chance of something good (pleasure, intimacy, status, being like everyone else) outdoes risks. To them it is worth the risk!  A sex education curriculum presented appears relevant to them

36.  Implementation on detention homes  Staff informed of the curriculum (origin,content, pedagogigs)  The curriculum used in the school setting  All participating youths: survey before and after  X participating youths: interviewed  Staffs’ experiences sought

37.  Do not be afraid to discuss sexuality with youths in residential homes. You do not have to be an expert, a willingness to listen and not judge is good enough.  Be reflexive regarding your reactions and actions when it comes to youths and their sexuality. Their sexuality is not (usually) a behaviour to treat or improve.

38.  Access to sexual health care (counseling, testing, contraception)

39.  All participating girls and boys!  Fellow doctoral students Lotta Carlström and Jack Lukkerz - for assisting during focus group interviews  Advisors professor Lotta Löfgren-Mårtenson and professor Sven-Axel Månsson – for everything, supervision is essential  The National Board of Institutional Care, SiS – for financing the research

40.  Thanks for listening!  Your comments or questions?! malin.lindroth@mah.se