Increasing attention has been directed towards the lack of sexual and reproductive health knowledge of international students,1–3 and people from culturally and linguistically diverse backgrounds living in Australia.4,5 No research has focused specifically on Japanese women living in Australia with regard to sexual health, contraceptive practices, sexually transmissible infections (STIs) and fertility.
Australia has the third largest population of Japanese residents in the world, and more than 30,000 Japanese people live in Sydney.6 This estimate is conservative, given that temporary visa holders, such as students studying in Australia for shorter than three months, are not included. Denman reports that, on the basis of Australian and Japanese figures, more than 63% of Japanese migrants are women.7 It is therefore probable that there are more than 18,000 Japanese women living in Sydney alone.
In a recent biannual national survey on sexual health in Japan, only 36% of sexually active men and women aged 16–49 years responded that they always used contraceptives, and approximately 19% responded that they sometimes used them. Among users, the most commonly used contraceptive methods were the condom (84%) followed by withdrawal (15%). Other methods reported were the Ogino method (a form of the rhythm method widely used in Japan; 4%), combined oral contraceptive pill (COCP; 4%) and intrauterine devices (IUDs; 1%).8
After more than 35 years of debate, the low-dose COCP was finally approved for use in Japan in 1999 – 38 years after it started being used in Australia.9,10 Multiple concerns about the possible negative effects of the COCP delayed its approval by the Japanese Ministry of Health and Welfare.9 These included concerns that the COCP could lead to possible adverse cardiovascular effects, further decline in the birth rate, deterioration of sexual morality, and spread of STIs. It has been argued that the social norms of Japanese society create barriers to accessing the COCP11 even though there is public awareness that condoms are less effective in preventing pregnancy.
One of the well-documented advantages of condoms are their effectiveness in preventing STIs, but it is questionable whether this issue is taken seriously in Japan. For instance, a recent study highlighted serious sexual health issues that need to be addressed in Japanese society. In 2015, the Japanese Foundation for Sexual Health Medicine found that 2.4% of 328,788 pregnant women screened in antenatal care were infected with chlamydia; the prevalence was particularly high among teenagers and women aged 20–24 years.12 Furthermore, another study of 1004 senior high school students found a very high prevalence of chlamydia among that student population (13% of females and 7% of males).13 Nearly 20% of students in the study did not use a condom at all when they had intercourse, and only 4% reported that they always used a condom. This study did not explore whether condoms were used correctly. Clearly, understanding how condoms are used would be more enlightening than figures simply indicating how many people use the method.14 Furthermore, Japanese researchers report that a lack of adequate sexual and reproductive health education still exists in Japan, and that even young Japanese people have strong negative attitudes towards the topic, and are too embarrassed to discuss or learn about sexual health issues.15,16 Changes in sexual health practices may first need to be implemented through attitudinal changes.
Although people’s cultural background is a key challenge in the promotion of sexual health programs and strategies for the prevention of STIs, very few health policies and strategies in Australia take into account the impact of the social and cultural background of migrants.17 Given that recent Japanese figures indicate an increase in the number of STIs, especially human immunodeficiency virus (HIV) and chlamydia in the younger population (<25 years),13 an understanding of the contraceptive and sexual practices of Japanese women in Australia would be helpful for doctors managing and interacting with Japanese patients.
It is unknown whether Japanese women living away from their country of birth have different contraceptive understandings, experiences and preferences from those living in Japan, or from other women living in Australia. This brief report presents findings from interviews with seven Japanese women living in New South Wales. Although this is a small number, the results provide new insights and have implications for practice and future research.
Method
Our study, approved by the University of New South Wales’s Human Research Ethics Committee (LP110200996), was a large qualitative study using open-ended, in-depth interviews to explore Australian women’s understanding of and experience with contraceptives in the context of their sexual lives (the Contraceptive, understanding, experience [CUE] study). A total of 94 women aged 16–49 years who had ever used contraceptives were recruited using snowball sampling between August 2012 and June 2013 in New South Wales. Seven Japanese migrants were included in the cohort. Women whose mother tongue was Japanese were given a choice of language (English or Japanese) for their interview, and all chose to be interviewed in Japanese. Each participant read and signed a consent form at the time of the interview and received A$30 as reimbursement for any expenses. The first author conducted all interviews in Japanese. The data were analysed in Japanese using an inductive thematic analysis, a procedure reported by Braun and Clarke.18 We took a social constructionist perspective, assuming that our understandings, feelings and perceptions are never absolute or static because we are regularly changing, and modifying meanings and interpretations through social interactions.19
Results
The seven Japanese women ranged in age from their mid-20s to their mid-40s. Two were married, one was in a de facto relationship and the remaining four responded that they were not in a live-in relationship at the time of their interview. Only one woman had a Japanese partner. Women’s duration of stay in Australia varied from three years to longer than 15 years.
The condom and withdrawal methods (sotodashi)
The condom and withdrawal methods were the most commonly used contraceptive methods by the Japanese women interviewed. This is supported by the most recent survey in Japan.8 All of the women reported that this combination was ‘standard practice for Japanese couples’.
Withdrawal is practised not only for the purpose of preventing pregnancy, but also to avoid any ‘uncleanliness’ from semen inside the woman’s body. In order to describe withdrawal, all of the Japanese women used the colloquial term sotodashi, which consists of the two words ‘outside’ and ‘discharge’. The word literally describes ejaculation of semen outside the vagina, and is therefore slightly different from English terms such as ‘withdrawal’ and ‘coitus interruptus’, which describe a practice without any reference to the semen itself. Although a few of the Australian women we spoke to referred to a general dislike of the ‘messiness’ that accompanied their partners ejaculating inside of them, none of the Japanese women interviewed had positive views about men ejaculating into their vagina unless they were intending to conceive.
Varying attitudes to contraceptive practice
All but one of the women had used the COCP at least once. Three had used it in Japan prior to coming to Australia, and three used it for the first time in Australia. The three women who had used the COCP in Japan had done so for the treatment of endometriosis, to ease menstrual pain or for cycle control purposes rather than for contraception.
Three women had used the emergency contraceptive pill (ECP) in Australia at the suggestion of their partners. All of these women admitted that they took it for extra assurance, subtly implying that they might be doing something wrong by taking it. Even Japanese women who were concerned about the hormonal side effects of the COCP were not overly concerned about the ECP because it was easy to obtain from a chemist and only taken as a single dose. Interestingly, a report released in 2012 by the Ministry of Health, Labour and Welfare in Japan stated that nearly 60% of the population did not know about the ECP.8 Attitudes towards the ECP and history of its use in Japan are unknown, but our research indicates that at least some Japanese women living in Australia do not hesitate to use it.
It [the emergency contraceptive pill] was suggested by my partner. It seemed he had had similar situations quite often … He was a sort of playboy type person, an English man [living in Australia]. He said it’s free in England … He said that a lot of young people encounter this situation in England and it’s quite common, so we can get it tomorrow. – Yurie
The use of dual or even triple methods to enhance protection from pregnancy was a common strategy. The combinations used were condom and withdrawal; condom and avoiding intercourse on high fertility days; COCP and withdrawal; and condom/COCP, withdrawal and fertility awareness method. Women did not always practise dual methods rigidly, and some said it depended on their mood and/or how serious the relationship was. The Japanese women interviewed had not had any unplanned pregnancies despite their use of methods considered by most doctors to be unreliable.20 Withdrawal is a practice that is culturally embedded in Japan,21 even though many doctors, including Japanese doctors, do not perceive it to be a valid contraceptive method.22
Two women expressed polarised attitudes to sexual practice. One woman reported that preventing pregnancy was, at one time, the first priority in her life because of her strong desire to follow the life plan she had set for herself. She therefore avoided sex and relationships altogether at this time in her life as the most guaranteed strategy for protecting herself from an unintended pregnancy. When she eventually became involved in a sexual relationship she preferred to use condoms she had bought herself so she could be sure of their quality and availability in the moment. This was a very different attitude from that of the other Japanese women, who clearly stated that ‘getting the condom is not our [women’s] responsibility. If men want to have sex, they should buy the condom’.
Another woman disclosed her ‘weakness’ when it came to protecting herself from pregnancy. She admitted that despite her understanding that contraceptive use was important, her rational thinking often faded when she gave herself over to her sexual desire during sex with someone she liked. If her partner did not want to use a condom, then she would allow him to have intercourse with her without one but ask him to withdraw. Australian women interviewed also reported avoiding using condoms or methods that interfered with their partner’s pleasure, but Japanese women tended to have more faith in withdrawal as a way of preventing pregnancy.
Table 1. Previously used and currently used contraceptive methods by seven Japanese women in New South Wales
|
| Pseudonym (Relationship status, age group) | Condom | Withdrawal | COCP | Ogino method | Abstinence | Emergency contraceptive pill | Current contraceptive method(s)* |
|---|
Sakura
(Live-in relationship, 40s) |
x |
x |
x |
|
|
|
No method used – low sex drive and perceived low fertility |
Yurie
(Live-in relationship, 30s) |
x |
x |
x |
x |
|
x |
Condom |
Kaede
(Non-live-in relationship, 20s) |
x |
x |
x |
|
|
x |
Condom, withdrawal and the Ogino method (sometimes) |
Haruko
(Non-live-in relationship, 30s) |
x |
x |
x |
x |
x |
|
Condom (sometimes) or withdrawal |
Natsue
(Non-live-in relationship, 20s) |
x |
x |
x |
|
|
|
Primarily condom and the COCP (for non-contraceptive purpose) |
Aki
(Live-in relationship, 30s) |
x |
x |
x |
x |
|
x |
No method – intending to conceive |
Fuyumi
(Non-live-in relationship, 30s) |
x |
x |
|
|
|
|
No method used – not in relationship at the time of interview |
Note: All of the women had completed at least 12 years of education in Japan. Some women had obtained tertiary education in Japan, while others had undertaken tertiary education both in Japan and Australia
*Current contraceptive method was derived from general open-ended questions throughout the interview |
Discussing contraception and sexual issues with a general practitioner
Inequality in access to services and contraceptive support among migrant and non–English-speaking women in Australia, despite generally high levels of education, have been reported.23 The Japanese women in our study similarly demonstrated inequality in access to services and contraceptive support. Most of the Japanese women interviewed expressed embarrassment about asking their general practitioner (GP) for the COCP. In particular, they described finding it awkward to explain or even pronounce ‘the pill’ properly. Many women had tried to raise it as a secondary issue during a consultation with their doctor, but had found this to be time-consuming and awkward. Some women disclosed that they had studied how to explain the COCP in English and looked for the appropriate words in a Japanese–English dictionary. One woman said she practised what she would say in the consultation. Women who had originally been prescribed the COCP for treatment purposes found it easier to ask the GP for a prescription, but the tendency to perceive the COCP as a medication for the treatment of a condition rather than for preventing pregnancy, together with the women’s reluctance to discuss it with the GP, meant that they often used an additional contraceptive method such as the condom or withdrawal.
Even going to the GP with a simple cold, I need to study the terminology using a dictionary and try to get the pronunciation right … It’s not easy … Once at the GP I said I wanted the ‘piru’ [pill] and he did not understand because I didn’t pronounce it right. ‘Piru’ is a difficult one .… It takes time and then making an appointment is also very stressful because I have to call them. – Kaede
The ‘piru’ (pill) is widely adopted as an English-Japanese word to describe the COCP in Japan, but pronunciation and the use of ‘a’ instead of ‘the’ in front of ‘piru’ may confuse Australian GPs. Even though our Japanese participants reported difficulty finding an appropriate English word to explain their bodily experiences, they did not necessarily want to go to a Japanese-speaking clinic. Some women preferred consultations with Australian doctors. One woman expressed concern about issues of confidentiality if she saw a Japanese doctor because of her perception that the Japanese community in Australia was small. This tendency to avoid receiving healthcare services from professionals with the same cultural background and seeking an alternative healthcare provider was reported in a study conducted in Western Australia,24 and was especially the case with unintended pregnancy and STIs.
The unspoken topic of STIs
STIs were an unspoken topic for the majority of Japanese participants, with the exception of one woman who disclosed her history of STIs and how this affected her relationship. She reported that her boyfriend’s request that she have a check-up for STIs worried and intimidated her because she feared she would be embarrassed by the consultation and any positive findings. When asked about STIs, many of the Japanese women expressed concern but tended to think that they themselves would not contract one. When discussing the use of condoms, the Japanese women did not refer to protection from STIs as one of the benefits. In comparison, a vast majority of non-Japanese women in our wider study spoke of protection from STIs as a benefit of condom use.
The tendency to see oneself as immune to STIs was addressed in a 2009 survey of the sexuality and sexual behaviour of Japanese college students.25 Australian healthcare providers may find it challenging to convince Japanese women, whose knowledge of STIs is limited, to undergo screening for STIs. However, women who participated in our study welcomed the straightforward approach of Australian doctors. A brief explanation that STI screening is standard practice may lessen women’s embarrassment because it communicates that they are not being targeted as a specific type of person. However, women’s perceptions that ‘Australian doctors do not ask you so much in detail’ and ‘they do not interfere with our privacy’ may suggest that communication between Australian doctors and their Japanese patients is not optimal. If women (and men) understand that screening is routine practice in Australia, they are more likely to accept it.
Discussion
The contraceptive and sexual practices of Japanese women living in Australia were largely based on what they considered to be ‘normal practice’ in Japan. Preference for the condom and withdrawal methods means that these women do not need to access healthcare professionals to obtain contraceptives. As a result, there may be only minimal opportunities for these women to discuss sexual healthcare checks. Although cervical screening provides an opportunity for women to discuss reproductive and sexual health with a doctor, there are no data available to indicate whether or not Japanese women participate in this screening program. Furthermore, presenting to a Japanese GP poses issues related to shame and confidentiality for these Japanese women, whereas with non-Japanese healthcare professionals, the language barrier makes it difficult for them to discuss contraceptive and sexual health issues. Even though the Japanese women interviewed for this study were taught English for longer than six years at school in Japan and some had studied in an Australian institution, their English pronunciation was poor when compared with their level of understanding of written English.
This was a qualitative study that gave voice to a small cohort of women who participated in a larger study. One of the study’s limitations was that it could not compare and contrast results on the basis of age, length of residency in Australia or relationship status. Nevertheless, a number of clinical and social implications can be considered.
Provision of information about sexual health and accessible facilities, as well as advertising about the availability of screening in Japanese community newspapers and leaflets at schools, colleges and universities would expose more Japanese people to the information they need. Information about sexual health and contraceptive options in Australia could also be effectively provided online via a purpose-built website or a Japanese language section of an existing website. Making use of available Japanese-speaking interpreters in sexual health consultations (preferably by telephone rather than face-to-face) would promote better communication and understanding between patients and health professionals. Furthermore, an educational program targeting Japanese students in Australia would not only provide insight into their existing sexual health knowledge but also enhance it. Evaluation of such a program would help to inform future research, programs and practice.
It is unrealistic to expect Australian GPs to be aware of the cultural practices of people from all ethnic minorities, but it is unhelpful for them to assume that all ethnic minorities share the same dominant attitudes. Our study highlights the need for GPs to use interpreters when needed, and to be proactive in finding out their patients’ attitudes and beliefs about sexual health issues rather than making assumptions or waiting for them to initiate the discussion.
Authors
Kumiyo Inoue RN (Japan and Australia), BN, MN, Grad Cert Public Health, PhD(USyd), PhD Scholar, University of New South Wales, Kensington, NSW; Adjunct Senior Researcher, School of Health Sciences, University of Tasmania, Hobart, Tas. k.inoue@student.unsw.edu.au
Marguerite Kelly B PsychSc (Hons 1), formerly Research Officer, University of New South Wales, Kensington, NSW; Western Sydney University, Parramatta, NSW
Deborah Bateson MA (Oxon), MSc (LSHTM), MBBS, Medical Director, Family Planning NSW, and Clinical Associate Professor, University of Sydney, NSW
Alison Rutherford BMed, MA, MPH, FAFPHM, FAChSHM, Conjoint Senior Lecturer, University of New South Wales, Kensington, NSW
Mary Stewart MBBS, DSFRH, MPH (Health Promotion), Senior Medical Officer, Research and Education, Family Planning NSW, Ashfield, NSW
Juliet Richters BA, MPH, PhD(USyd), Professor, School of Public Health and Community Medicine, University of New South Wales, Kensington, NSW
Competing interests: Deborah Bateson and Mary Stewart’s institution has, outside this work, received payment for lectures and expenses from Bayer Healthcare and MSD.
Provenance and peer review: Not commissioned, externally peer reviewed.
Acknowledgements
We would like to thank Professor Alexandra Barratt of the School of Public Health at the University of Sydney who reviewed the final version of the paper. We gratefully acknowledge the contributions of study participants. Kumiyo Inoue, Alison Rutherford, Juliet Richters and Marguerite Kelly received grants from the Australian Research Council (ARC) for this work. Juliet Richters received travel grants from the ARC and Family Planning NSW.