National Guide

Chapter 7 | The health of young people

Sexual and Reproductive health







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      4. Sexual and Reproductive health

The health of young people | Sexual and Reproductive health in adolescence 

Dr Annapurna Nori, Dr Talila Milroy  

Key messages

  • Aboriginal and Torres Strait Islander young people can make better informed choices regarding their sexual and reproductive health when they feel respected and treated with dignity.
  • Sexual health is not merely the absence of disease, but also involves respect, safety and freedom from discrimination and violence.1
  • Sexual and reproductive health services for Aboriginal and Torres Strait Islander youth should be underpinned by an understanding of social and emotional wellbeing (SEWB) principles and strengths-based approaches.
  • Screening, education (including anticipatory guidance) and behavioural interventions can be complemented by specific advice regarding contraception and intentional pregnancy.
  • Sexually transmissible infections (STIs) are a major contributor of disease in Aboriginal and Torres Strait Islander young people, especially those in remote and regional Australia.2,3
Type of preventive activity - Immunisation 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People aged 12–24 years Check vaccination records, including the Australian Immunisation Register, to ensure all vaccinations are up to date and offer vaccination if required Opportunistically Strong National resource and national guideline4,5 Immunisation is an effective means of primary prevention
People aged 12–24 years Provide education on vaccination safety, benefits and efficacy Opportunistically Good practice point Single study6 Recommendation from a healthcare provider is an important driver to support vaccination uptake
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People aged 12–24 years Enquire whether menses have commenced and provide menstrual health counselling and education Opportunistically Good practice point National resource5 Aligns with a comprehensive approach to sexual and reproductive health
People aged 12–24 years Enquire whether sexually active as part of a broader assessment of health and wellbeing Opportunistically Good practice point National resource5 Aligns with a comprehensive approach to sexual and reproductive health

Establishing rapport and trust is essential for young people to feel and be safe discussing sex and sexuality
People aged 12–24 years If sexually active, assess sexual risk taking and sexual safety Opportunistically Strong National resource, Aboriginal and Torres Strait Islander single study and narrative review5,7,8 Aligns with a comprehensive approach to sexual and reproductive health
People aged 12–24 years If sexually active, offer testing for STIs, including chlamydia, gonorrhoea, HIV and syphilis (and additional if indicated)

Refer to Chapter 13: Sexually transmissible infections and blood-borne viruses		 Opportunistically Strong National guidelines9,10 Aligns with a comprehensive approach to sexual and reproductive health
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People aged 12–24 years Provide anticipatory guidance around safer sex and contraception Opportunistically Good practice point National resource and Aboriginal and Torres Strait Islander resource5,11,12 Aligns with a comprehensive approach to sexual and reproductive health
Type of preventive activity - Medication
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People aged 12–24 years Discuss and offer contraception, especially long-acting reversible contraceptive as first-line method Opportunistically Strong National resource and national guideline5,13 Aligns with a comprehensive approach to sexual and reproductive health
People aged 12–24 years Provide education on when and where to seek emergency contraception Opportunistically Good practice point National resources and national position statement5,14 Aligns with a comprehensive approach to sexual and reproductive health
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Primary healthcare service providers Incorporate the knowledge and lived experience of local Aboriginal and Torres Strait Islander communities, especially Elders and youth, into management plans and program design and delivery Ongoing Strong Aboriginal and Torres Strait Islander-specific single study7 Important when developing sexual health programs including outreach and health promotion
Primary healthcare service providers Promote and provide community-based and youth-led sexual health programs, including as outreach Ongoing Good practice point Aboriginal and Torres Strait Islander-specific review15 To promote engagement of young people in their sexual and reproductive health
  • Provide health information through multiple formats, such as digital (social media, online events), groups (workshops, community events) and newsletters (paper-based and digital).
  • Ensure all staff have cultural safety and youth-friendly training appropriate to their roles.
  • Ensure clinic resources, waiting room materials and displayed information on sexual health are culturally safe, youth friendly and up to date.

Background

The period between the ages of 12 and 24 years is a time of major sexual and reproductive development for all young people, involving significant transitions in cognition, physical changes and emotions. Young people experience varying degrees of turbulence during this time, and sexual and reproductive health is often a confronting area for them.5 As per the Queensland Health Aboriginal and Torres Strait Islander adolescent sexual health guideline, ‘In seeking sexual healthcare, feeling protected, empowered and culturally safe is important for the Aboriginal and Torres Strait Islander young person’.16 Strengths-based approaches, cultural sensitivity and social and emotional wellbeing principles are therefore essential in interactions around this health topic.

Sexual and reproductive health is defined as ‘a state of complete physical, mental and social well-being in all matters relating to the reproductive system’.17 The World Health Organization explicitly states that sexual health is not merely the absence of disease, but also ‘involves respect, safety and freedom from discrimination and violence’.18 Therefore, sexual and reproductive health encompasses (but is not limited to) puberty (physical, mental and emotional changes); menstruation, including menarche; sexual identity and safety; safer sex practices and protection; contraception; and family planning. Primary care providers are the main option for young people regarding sexual and reproductive health education and services.

Supporting cultural and sexual identity and respect for their bodies, promoting respectful relationships and good sexual health form part of the key priorities for improving young people’s health in Australia.16,19 Understanding the concept of and respecting gendered cultural protocols around women’s business and men’s business is an important aspect of cultural sensitivity.16 Sensitivities associated with the concept of ‘shame’ (stigma, embarrassment, reluctance) also need to be factored in.

STIs especially chlamydia and gonorrhoea, are a major contributor of disease in Aboriginal and Torres Strait Islander young people, especially those in remote and regional Australia2,3 (see Chapter 13: Sexually transmissible infections and blood-borne viruses).

There is limited knowledge about Aboriginal and Torres Strait Islander young people’s experiences of sexual and reproductive health care, and in particular experiences surrounding unintended pregnancy.20,21 The evidence suggests that contraceptive use patterns are different for Aboriginal and Torres Strait Islander people compared with non-Indigenous Australians.22 For example, social determinants, intergenerational experiences with pregnancy and teenage motherhood and social mores, such as pregnancy being a rite of passage to adulthood, can influence how a young person views contraception and sexual relationships.7 A 2020 systematic review reported that beliefs regarding contraception were influenced by cultural norms (which themselves vary between community groups), notions of taboo, and gender roles.21 Contraceptive use was influenced by long-term versus short-term relationships, desires surrounding pregnancy and reproductive coercion.21

A 2021 study involving sexual and reproductive health information for urban Aboriginal and Torres Strait Islander women and men aged 16 years and over found the participants viewed family, kin and friends as key knowledge holders, and Aboriginal and Torres Strait Islander Community Controlled Health Organisations (ACCHOs) as key knowledge spaces.7 In addition, historical control of Aboriginal and Torres Strait Islander women’s reproduction and removal of autonomy may have ongoing influence on attitudes towards contraception and sexuality.7,21

Unintended pregnancy is common, with estimates that nearly one in four pregnancies in Australia are unplanned.23 In 2021, babies born to women in Australia aged under 20 years accounted for 1.5% of all births, with the number of teenage mothers giving birth more than halving since 2010.24 The proportion of Aboriginal and Torres Strait Islander mothers aged under 20 years also fell, from 20% in 2010 to 11% in 2020.24 Teenage pregnancy in general is associated with socioeconomic disadvantage, and social and health implications include increased risk of domestic violence, mental health disorders, being underweight in pregnancy, STIs, substance use and financial instability.8,24 Most infants of teenage mothers will have positive health outcomes, but there is an increased likelihood of preterm birth, low birthweight and higher morbidity and mortality.24

There have been improvements in reproductive health, such as increased rates of antenatal care and decreased rates of smoking.24 However, problems that can complicate pregnancies, such as pre-existing diabetes, obesity, alcohol intake and smoking during pregnancy, are generally more prevalent in Aboriginal and Torres Strait Islander women.24 These factors must be addressed in the context of social determinants of health and the crucial element of self-determination that honours agency and intention. A good starting point is to respect individual and community beliefs and values surrounding pregnancy, motherhood and childrearing and to negotiate a consensus regarding women’s reproductive health.20,23–25

A practical example of successful implementation is the Aboriginal Family Birthing Program in South Australia.26 Building on the 2004 Anangu Bibi Birthing Program in Port Augusta, the program offers cultural, social and clinical support for the antenatal, intrapartum and early postnatal periods through Aboriginal maternal infant care workers.

Empowering knowledge holders (community members [especially Elders], family and peers) and supporting knowledge spaces (primary care providers) to deliver community-led and community-designed programs may help young people engage positively with sexual and reproductive health.7

Offering a variety of approaches, such as yarning circles to facilitate open and interactive discussions, digital technology and peer-led sessions, can have wider appeal and reach.7,15,27 Deadly Choices is a health promotion initiative of the Institute for Urban Indigenous Health that includes web-based activities and is widely used by ACCHOs for health promotion.28

Gender diversity

Although data on the prevalence of Aboriginal and Torres Strait Islander gender diversity is scarce, it is clear this diversity exists and that Aboriginal and Torres Strait Islander lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual (LGBTQIA) people face significant discrimination in the form of abuse, violence and isolation within and outside of their communities, and a lack of access to healthcare.29,30 Consequently, they are at much higher risk of mental illness, including self-harm and suicide, and STIs.

Aboriginal and Torres Strait Islander LGBTQIA youth have to negotiate the trifecta of adolescence, cultural identity and gender diversity, making this a ‘complex issue that includes processes of disconnection, connection and reconnection with family, community, culture and Country’.30

Design of services (environmental)

The environment in which young people access healthcare includes the physical environs and ambience of the health service, as well as the relational sociocultural aspects (knowledge, attitudes and behaviour) of all staff members. Youth friendliness and cultural safety are essential to all aspects of service delivery to Aboriginal and Torres Strait Islander youth, including in sexual and reproductive health care.31 These elements have been well described in the Introduction to this chapter.

To summarise, culturally safe organisations respect cultural identity and recognise the strengths of young people and communities while being aware of the harsh legacy and adverse health consequences of colonisation. Welcoming, non-judgemental, accessible and affordable environments that actively involve young people also support engagement and cultural safety.

Health promotion initiatives should be Aboriginal and Torres Strait Islander led and multidisciplinary, and should involve and support local knowledge holders (family, Elders and peers) and trusted knowledge spaces, such as ACCHOs.7 Providing health information through workshops, online events, social media newsletters and community events is effective.31

There has been very little formal evaluation of the effectiveness of primary pregnancy and STI prevention programs in young people, and even less for Aboriginal and Torres Strait Islander youth. Many established programs are evaluated in heterogeneous ways, making comparisons difficult, and the availability of programs varies across jurisdictions. However, there is strong evidence that combining educational curriculum interventions with community outreach can be effective in preventing teenage pregnancy and risky sexual behaviour. A 2009 review evaluated Australian and international sexual health programs that had a focus on Indigenous youth.15 The review found that school-based sex education (possibly occurring before the onset of sexual activity), small group skills building, outreach programs, including targeted condom distribution, and community-level outreach are effective for preventing sexual risk behaviours.15 Abstinence programs were the least successful intervention and are not recommended.

Screening and behavioural interventions

Australian recommendations for sexual and reproductive health emphasise the importance of:

  • age- and developmentally appropriate advice regarding sexuality and reproduction
  • screening for sexual activity and risky sexual behaviour
  • the use of anticipatory guidance counselling within non-judgemental and youth-friendly forms of communication.5,14

As stated previously, anticipatory or health guidance is proactive advice appropriate to a young person’s stage of development.5,11 The adolescent health GP resource kit advocates for this approach, as well as screening for sexual concerns, STIs and pregnancy intentions within a framework of screening for protective factors and risk taking5 (see Useful resources).

Questions surrounding sexual orientation and sexuality are important and should be approached in a non-judgemental way, keeping the whole person in mind, with sensitivity to the young person’s preferences and in accordance with local cultural protocols. Exploring issues such as contraception, pregnancy intention, safer sex practices and the use and knowledge of condoms and emergency contraception is appropriate once a trusting relationship has been established and the young person indicates they are comfortable.7,8 A much greater level of sensitivity must be applied to discussions regarding sexual safety and asking about sexual harassment, coercion, abuse and assault.

Australian national STI management guidelines recommend offering STI testing (chlamydia, gonorrhoea, syphilis and HIV) at least annually to young Aboriginal and Torres Strait Islander people under the age of 30 years who are not in a stable long-term single-partner sexual relationship.9 Trichomoniasis screening may be appropriate in Aboriginal and Torres Strait Islander communities with higher prevalence. Point-of-care testing for chlamydia, gonorrhoea and trichomoniasis is available in many ACCHOs.

The Australian STI management guidelines also advocate giving the person a choice of clinician gender and having an Aboriginal/Torres Strait Islander health worker or practitioner present for part of or the entire consultation.9 It is also appropriate to offer self-collection where the person is uncomfortable with clinician-collected samples, and especially if there is no clinical imperative for a physical examination.

The education of caregivers of young people about how they can engage them in discussions about sexual health is important. A 2015 survey of Aboriginal caregivers in Western Australia revealed that caregivers wanted to discuss sexual safety and body autonomy with their developing children, and the book Yarning quiet ways was developed as a guide to have these conversations.32 

Contraception

Providing advice on and access to all methods of hormonal contraception is considered a core activity of Australian primary healthcare/general practice.33 Effective contraception can prevent unintended pregnancy in young people. It can be provided without parental or guardian consent to a young person below the age of consent for medical treatment if the young person is assessed as competent to make that decision.13 Information on contraception should be accompanied with education on STI prevention (eg the use of condoms). The Australian Therapeutic guidelines provide detailed information on each type of contraception including indications and contraindications.13

Barrier methods of contraception, especially male condoms, are effective for both pregnancy prevention and reducing the risk of some STIs.34 Counselling on condom use is recommended as primary prevention and must be accompanied by education about how to access them, the importance of proper and consistent use and guidance on additional forms of contraception.34 Peer condom distribution and community-based condom distribution are specific strategies that may be useful for Aboriginal and Torres Strait Islander young people in remote communities as part of broader youth-led STI prevention and sexual health programs that support harm minimisation.35

Long-acting reversible contraception methods, such as etonogestrel implant and intrauterine devices (IUDs), are the first-line choice for young people.34,36 IUDs can be safely used by young nulliparous individuals. Depot medroxyprogesterone injection is generally considered safe in adolescence, but is less preferred due to a theoretical reduction in peak bone mineral density in this age group.13 A study that explored contraceptive views in a group of rural Aboriginal women showed a preference for the etonogestrel implant compared with the depot injection, but there was a low use of IUDs in this group due to accessibility issues.37

Combined oral contraceptives are less reliable in younger people due to user reliance, but can offer non-contraceptive benefits such as acne control and cycle manipulation, which may appeal to young people. Progesterone-only pills have higher failure rates in those under 25 years due to high background fertility rates.13

Education about and access to emergency contraception is important for and safe in young women.5,14 High-dose levonorgestrel is the emergency contraceptive pill in Australia, and young women can obtain it via a pharmacist without a prescription. The insertion of a copper IUD within five days of unprotected intercourse is also an option, but in practice there are barriers to accessing it in a timely manner.14

Immunisation

The Australian immunisation schedule for young people includes human papilloma virus primary vaccination as well as hepatitis B boosters.4 In most jurisdictions these are offered through school immunisation programs. However, it is important for primary health providers to ask about these and other routine immunisations, check the Australian Immunisation Register for immunisation status (especially for young people who are not attending school, or may have missed out on the vaccinations) and to provide vaccinations that have been missed.4–6

  1. World Health Organization (WHO). Adolescent and young adult health. WHO, 2023 [Accessed 26 April 2024].
  2. Azzopardi PS, Sawyer SM, Carlin JB, et al. Health and wellbeing of Indigenous adolescents in Australia: A systematic synthesis of population data. Lancet 2018;391(10122):766–82. doi: 10.1016/S0140-6736(17)32141-4.
  3. Ward J, Bryant J, Wand H, et al. Sexual health and relationships in young Aboriginal and Torres Strait Islander people: Results from the first national study assessing knowledge, risk practices and health service use in relation to sexually transmitted infections and blood borne viruses. Baker IDI, 2014 [Accessed 26 April 2024].
  4. Department of Health and Aged Care. Immunisation for adolescents. Australian Government, 2018 [Accessed 26 April 2024].
  5. Chown P, Kang M, Sanci L, Newnham V, Bennett DL. Adolescent health: Enhancing the skills of general practitioners in caring for young people from culturally diverse backgrounds, GP resource kit. 2nd edn. NSW Centre for the Advancement of Adolescent Health and Transcultural Mental Health Centre, 2008 [Accessed 26 April 2024].
  6. Davies C, Skinner SR. Adolescent vaccination – the important role of GPs. Med Today 2022;23(3):14–24.
  7. Hickey S, Roe Y, Harvey C, et al. Community-based sexual and reproductive health promotion and services for First Nations people in urban Australia. Int J Womens Health 2021;13:467–78. doi: 10.2147/IJWH.S297479.
  8. Mann L, Bateson D, Black KI. Teenage pregnancy. Aust J Gen Pract 2020;49(6):310–16. doi: 10.31128/AJGP-02-20-5224.
  9. Australasian Society for HIV Viral Hepatitis and Sexual Health Medicine (ASHM). Australian STI management guidelines for use in primary care. ASHM, 2022 [Accessed March 2023].
  10. headspace (National Youth Mental Health Foundation). Clinical toolkit. At risk group: Young men. headspace, 2020 [Accessed March 2023].
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  12. Richmond TK, Freed GL, Clark SJ, et al. Guidelines for adolescent well care: Is there consensus? Curr Opin Pediatr 2006;18(4):365–70. doi: 10.1097/01.mop.0000236383.41531.8e.
  13. Therapeutic Guidelines Limited. Contraception. In: Therapeutic guidelines, sexual and reproductive health. Therapeutic Guidelines, 2021 [Accessed 26 April 2024].
  14. The Royal Australasian College of Physicians (RACP). Sexual and reproductive health care for young people: Position statement. RACP, 2015 [Accessed March 2023].
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  16. Queensland Health. Aboriginal and Torres Strait Islander adolescent sexual health guideline. Queensland Government, 2013 [Accessed March 2023].
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  19. Department of Health. National action plan for the health of children and young people 2020–2030. Australian Government, 2019 [Accessed 26 April 2024].
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  21. Coombe J, Anderson AE, Townsend N, et al. Factors influencing contraceptive use or non-use among Aboriginal and Torres Strait Islander people: A systematic review and narrative synthesis. Reprod Health 2020;17(1):155. doi: 10.1186/s12978-020-01004-8.
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  31. National Office for Child Safety. Keeping our kids safe: Cultural safety and the national principles for child safe organisations. Australian Government, 2021 [Accessed 26 April 2024].
  32. Department of Health. Yarning quiet ways: Teaching kids to have strong, safe and healthy relationships. Government of Western Australia, 2015 [Accessed March 2023].
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  34. National Institute for Health and Care Excellence (NICE). Contraceptive services for under 25s. NICE, 2014 [Accessed March 2023].
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  36. The American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care, Long-Acting Reversible Contraception Work Group. Adolescents and long-acting reversible contraception: Implants and intrauterine devices. ACOG, 2021 [Accessed 26 April 2024].
  37. Griffiths EK, Marley JV, Friello D, Atkinson DN. Uptake of long-acting, reversible contraception in three remote Aboriginal communities: A population-based study. Med J Aust 2016;205(1):21–25. doi: 10.5694/mja16.00073.




 

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