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1. Introduction
Engaging in sexually intimate relationships in a foreign country can lead to unsafe sexual experiences and poor sexual health outcomes, especially for those who are newly sexually active. International education practitioners act as important intermediaries between health services that provide sexual health advice to cross-border learners. Practitioners thus need to be prepared, cognisant of the cultural context and dimensions, and aware of available resources and referral opportunities.
2. Factors influencing sexual health outcomes for international students
2a. Sexual health knowledge
Many international students lack knowledge about safe sex practices and may not be equipped to avoid unwanted pregnancies and sexually transmitted infections (STIs). A review of 22 studies of diverse cross-border learners found that Asian international students specifically were less knowledgeable about sexual and reproductive health, including STIs and preventative measures, than domestic students and other Western international/exchange students (Lim et al 2022). Research also shows that international students are disproportionately affected by adverse sexual and reproductive health outcomes (Mundie et al 2021).
Poor sexual health knowledge is likely to be related to limited sex education by parents and schools in their home countries, and the fear of being judged if students are seen to attend a doctor or an educational event to learn more about sexual health. Lim et al (2022) found that Asian female international students, in particular, knew little about available contraceptive options, suggesting minimal sex education back home. Similarly, sex education in schools in India is general and minimal.
2b. Cultural considerations
Cross-border learners have to negotiate cultural differences and unfamiliar student support systems upon arrival in Aotearoa. Many students do not speak English as their first language and may find it difficult to express and share their concerns.
In addition, many international students come from more conservative countries where sexual health is often considered a taboo subject. Conservative traditions within various world religions (e.g., Christianity, Islam, Orthodox Judaism, and Hinduism) also view sex as something that should only occur within the confines of heterosexual marriage. Students coming from these cultural and religious contexts may be reluctant to seek help or treatment, which may result in worse health outcomes. Students may also be hesitant to seek help over fears that medical professionals are unfamiliar with their cultural beliefs and perspectives towards sexual health.
However, moving away from conservative norms back home may lead some international students to change their sexual behaviour. The international education experience for female students, in particular, is often accompanied by a feeling of sexual liberation, where they are more inclined to explore their sexuality without judgements from family and friends (Lim et al 2022). However, attitudes to premarital sex are often complex, and this tension between a conservative upbringing and a more liberal culture in Aotearoa may lead to conflicting behaviours. For example, cross-border learners may accept that their friends might have premarital sex, while still being afraid of judgement or disapproval if they behave in the same way (Burchard et al 2011).
2c. Contraception use
Research shows that international students generally engage in less risky sexual behaviours than domestic students. They also tend to have fewer sexual partners and higher condom usage on average. The higher rate of condom use among cross-border learners has been attributed to misconceptions about the effect of oral contraceptive pills on fertility (Lim et al 2022).
While this would appear to be good news, international students may also have difficulty accessing sexual health information and may have poor understanding of the role of general practitioners (GPs) as counsellors and sources of information about sexual healthcare (Burchard et al 2011). As a result, they may be less likely to seek help with contraception from a medical professional, which may be exacerbated by embarrassment, the fear of discovery, restrictive health insurance, and difficulties in navigating a foreign healthcare system (Lim et al 2022).
3. Providing international students with sexual health support
So to summarise, compared to domestic students, cross-border learners (especially those from non-Western, more conservative countries) typically:
- Have less knowledge about sexual healthcare
- Have more conservative sexual behaviour, although some may be exploring their sexuality for the first time
- Have difficulty accessing sexual healthcare services, because of the challenges in navigating a new health system as well as shame and fear of judgement.
So what does this mean for international education practitioners who want to support international students with their sexual health?
Here are some recommendations for ways your school or organisation might support students in this area.
Culturally appropriate education
Westernised sexual health education programs may be inappropriate for cross-border learners because of the social stigma that is often attached to sexual education in more conservative countries. You might therefore consider developing culturally appropriate education programmes, which should include education on the role of GPs in discussing sexual health, and guiding students toward reliable online information sources (see resources at the end of this module for some suggestions).
For Chinese international students, Lim et al (2022) suggest the use of popular social network platforms (e.g., WeChat, Renren) to facilitate dissemination of sexual health information.
3a. Tips for communicating with students from other cultures about sexual healthcare
- A respectful and curious attitude can help practitioners create a safe and open space for honest discussion. Additionally, taking the time to understand cultural and religious beliefs can help you understand why students have certain beliefs about sex and sexual healthcare.
- Consider a medical interpreter or providing information in students’ native language. Students might need help with English words for body parts or idioms. Identify diverse and multilingual health providers who understand your students’ cultural backgrounds and may be able to make students more comfortable in speaking about sensitive topics.
- Shame and stigma are key barriers for many students. Make sure students understand that anything they share is confidential, won’t be shared with their family and friends, and won’t be judged.
- Don’t insert your own beliefs or opinions into any of your interactions with students. Affirm that students have a range of values and beliefs, and practice displaying ease in discussing topics related to sexuality.
3b. Helping cross-border learners stay safe online
Online sexual behaviours – including pornography (porn), sexting (receiving or sending sexual messages, photos or videos), and unsolicited nudes (nude images or videos sent to someone who hasn’t asked for them) – are increasingly common, especially among young people. Some international students may be hearing about or experiencing these things for the first time, so practitioners should equip students with the knowledge and information they need to stay safe online.
The Light Project has developed resources for schools and educators on the new porn landscape and its impact on young people, including tips on starting a conversation, a porn use self-assessment and reliable information on porn for young people. The organisation acknowledges, however, that these resources may not meet all the specific needs of some cultural or religious groups, so you may need to think about how to adapt them to the specific needs of your international students, and the Light Project may be able to assist.
NauMai NZ also has information for students on how to stay safe online.
4. Common questions from international learners on sexual healthcare
Where can I find confidential advice on contraception and STIs?
Cross-border learners may not be aware that GPs can provide advice on sexual healthcare, including contraception and STIs, as often that is not the case in other countries. Ensure students understand the costs involved, but also the importance of seeking help.
- Sexual Health Clinics, which are located around the country offer free and confidential sexual healthcare, with no referral needed.
- Family Planning offer services such as contraception, STI checks and treatment, cervical smear tests, and pregnancy testing and advice. Family planning does charge for non-residents.
- The Burnett Centre, NZ AIDS Foundation provides HIV and STI testing as well as free counselling services.
- This Health Navigator website has a wealth of resources and links to other websites with reliable information on sexual healthcare.
- Just the Facts has lots of accessible information on STIs and where to get help and advice.
You may also want to encourage the student to learn more about consent and healthy relationships. Find out more in this module on relationships.
NauMai NZ has information for students on sexual healthcare, including contraception and STIs.
I’ve been sexually assaulted or experienced harmful sexual behaviour. What should I do?
Reassure the student that their complaint will be dealt with confidentially and professionally, and that you will support them every step of the way.
Ensure the student understands that it is their choice whether to disclose the incident, but that no matter what, you are there to support them. The following recommendations from the University of Auckland suggest how to report a sexual assault.
If the sexual assault has just happened:
- Make sure the student is now safe.
- Make sure they have support from a friend, flatmate, or family member.
- Offer to go with them to the Hospital Emergency Department. The hospital can assist the student to call the Police if they want them to. The New Zealand Police can provide trusted assistance in these situations.
Suggest that the student:
- Does NOT shower, bathe, wash clothes, or eat and drink (if there has been oral contact with saliva or semen) until they make a decision about involving the Police.
- Collect any urine they pass – any container will do – and note the time. Put it in the fridge or freezer. This is really important, if the student thinks they may have been drugged.
If the student wishes to report the incident directly to the Police, they have specialised sexual assault teams that will talk through the process of what happens next. If the sexual assault has just happened, the student can either call 111 – or they can go to a Police station. It is recommended that if the student is going to a Police station you ring first and ask that someone from the sexual assault team be there to meet you.
Ensure that you have counsellors and health professionals ready to help if a sexual assault or similar incident occurs.
You can learn more about preventing sexual violence in the relationships topic.
Will anyone know if I seek advice?
International students may need special reassurance that they can seek confidential and non-judgemental advice from a healthcare provider, without their family and friends knowing. Going to a GP or general health service means that no one will know what type of help the student is after. Reassure them that medical professionals are bound by ethical standards to keep their information private and confidential.
Are contraceptives free in New Zealand?
Generally, international students’ medical insurance is unlikely to cover sexual healthcare such as contraception, cervical screening, treatment for STIs, and pregnancy services. However, condoms may be freely available at your Student Health Centre or at a Sexual Health Centre. It’s important that students understand that sexual healthcare services may be expensive.
I’m part of the LGBTQIA+ community. Where can I get inclusive support and advice on sexual healthcare?
See this topic for more information on supporting LGBTQIA+ cross-border learners. Just the Facts have a list of sexual health support services specifically tailored for the rainbow community. Reassure students that in New Zealand, medical professionals are generally open and accepting of students of all ages, cultures, genders and sexual orientations.
5. Summary
This topic has helped international education practitioners adopt a more tailored approach to advising international students about sexual healthcare in Aotearoa. This will help protect students from harm, and ensure they know how to remain healthy. The following resources may be useful for readers who want to learn more, or for sharing with your cross-border learners.
6. References
Allianz Digital Health Service, which includes the Allianz Care app: an online triage service for students in trouble
A Compact Guide to Sexual Health - HE1438
Family Planning online resources
Sexual healthcare in New Zealand | NauMai NZ
Sexual and reproductive health | Ministry of Health NZ
Sexual health support services
Burchard, A., Laurence, C., & Stocks, N. (2011). Female international students and sexual health - a qualitative study into knowledge, beliefs and attitudes. Australian family physician, 40(10), 817–820. https://pubmed.ncbi.nlm.nih.gov/22003488/
Lim, M. S. Y., Hocking, J. S., Sanci, L., & Temple-Smith, M. (2022). A systematic review of international students’ sexual health knowledge, behaviours, and attitudes. Sexual health, 19(1), 1–16. https://doi.org/10.1071/SH21073 https://pubmed.ncbi.nlm.nih.gov/35177186/
Mundie, A., Lazarou, M., Mullens, A. B., Gu, Z., & Dean, J. A. (2021). Sexual and reproductive health knowledge, attitudes and behaviours of Chinese international students studying abroad (in Australia, the UK and the US): a scoping review. Sexual health, 18(4), 294–302. https://doi.org/10.1071/SH21044
