Sexual and Reproductive Health Matters ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/zrhm21 An in-depth analysis of the sexuality needs of Barcelona’s youth: a holistic view using mixed method Lluís Forcadell-Díez, Jordi Baroja Benlliure, Cristina Martínez & Gloria Pérez To cite this article: Lluís Forcadell-Díez, Jordi Baroja Benlliure, Cristina Martínez & Gloria Pérez (2022) An in-depth analysis of the sexuality needs of Barcelona’s youth: a holistic view using mixed method, Sexual and Reproductive Health Matters, 30:1, 2135728, DOI: 10.1080/26410397.2022.2135728 To link to this article: https://doi.org/10.1080/26410397.2022.2135728 © 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group Published online: 18 Nov 2022. Submit your article to this journal Article views: 941 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=zrhm21 RESEARCH ARTICLE An in-depth analysis of the sexuality needs of Barcelona’s youth: a holistic view using mixed method Lluís Forcadell-Díez ,a,b Jordi Baroja Benlliure,c,d Cristina Martínez,e,f Gloria Pérez g,h,i,j a Predoctoral Researcher, Agència de Salut Pública de Barcelona, Barcelona, Spain. Correspondence: lforcade@aspb.cat b PhD Candidate, Universitat Pompeu Fabra, Barcelona, Spain c Director, Centre Jove d’Atenció a les Sexualitats, Barcelona, Spain d Associate Professor of Sexual Health, Universitat Oberta de Catalunya, Barcelona, Spain e Director, Programa d’Atenció a la Salut Sexual i Reproductiva, Institut Català de la Salut, Barcelona, Spain f Associate Professor of Nursing, Universitat de Barcelona, Barcelona, Spain g Responsible for Sexual and Reproductive Health Information Systems, Agència de Salut Pública de Barcelona, Barcelona, Spain h Associate Professor of Medicine and Public Health, Universitat Pompeu Fabra, Barcelona, Spain i Researcher, Institut d’Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain j Researcher, CIBER de Epidemiología y Salud Pública, Madrid, Spain Abstract: A positive experience of sexuality during youth is key to good sexual health later in life. Addressing young people’s sexual health needs and sexual and reproductive rights is thus essential. This study aimed to identify unmet sexual health needs among youth in the city of Barcelona (Spain) through mixed methods research. We analysed the narratives of young people (n = 50) aged 14–24 years with different genders, origins, sexualities and socioeconomic backgrounds, collected from January to April 2019. A descriptive statistical analysis was also conducted on the records of visits to sexual health services and reasons for consultation. We found that 21% (n = 32,161) of young people aged 14–24 years had used sexual healthcare services in Barcelona between 2015 and 2017, while the reasons for consultation differed across sex, gender and socioeconomic background. Young people declared that they needed more information to enjoy their sexuality, to know where to go in case of an unexpected situation and to learn how to combat gender-based violence. They stated that the sexuality education they had received was sparse and focused on risks. We found that formal sex education is scarce, with informal sex education thus acquiring a major role. Current services can be improved by expanding coverage, training professionals and reducing acceptability and accessibility barriers. Sexism is ubiquitous in young people’s sexual, dating and personal relationships. We recommend planning sexual health care services and formal sexual education, in which a strong gender strategy is embedded, as part of the same strategy. DOI: 10.1080/26410397.2022.2135728 Keywords: qualitative research, young adult, sexual health, reproductive health services Introduction based on respect for and the guarantee of the sex- Sexuality is a central aspect of a person’s life, which ual rights recognised by the Cairo Declaration.3 manifests itself in all stages of the life cycle.1 A posi- The experience of sexuality is determined by tive experience of sexuality during youth contrib- both contextual and individual levels. At the con- utes to good sexual health later in life. Sexual textual level, the construction of sexualities main- health is defined as a complete state of physical, tains a close relationship with the social, emotional and mental well-being in relation to historical, cultural and political context, with sexuality.2 Good sexual health is achieved through two significant elements. On the one hand, in a positive approach to sexuality, and the possibility Spain, as in many other societies in the global of having pleasurable affective sexual relationships North, today’s postmodern vision of sexuality combines the values of individualism and © 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group 231 This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 hedonism with inherited religious values.4 This been established for the care of young people,21 to impacts on constructions of sexuality during determine whether services are youth-friendly. The youth with phenomena such as the hook-up cul- following barriers to their use have also been ident- ture5 and pornography at the same time as the ified: availability of services, accessibility and accept- perpetuation of sexualities as taboo. On the ability of services for youth and quality of services.22 other hand, contemporary societies in the global Studies have also identified the role and attitudes North are also characterised by a set of factors required by professionals caring for young people and mechanisms that configure social hierarchies in order to provide high-quality care.23 through the axes of inequality.6 Through the At the individual level, sexualities are con- mechanisms of gender binarism, and the institu- structed based on a person’s individual experience tionalisation of heterosexuality, romantic love and social interactions with other people. The and monogamy, the patriarchal system contrib- construction of an individual’s sexuality begins utes to inequalities and reinforced gendered at the same time as his or her socialisation. Sexual experiences of sexuality.7 Thus, patriarchy gener- socialisation is the process by which certain beha- ates and reproduces social inequalities and pun- viours are reinforced or rejected according to the ishes dissidents.8 Other axes of inequality also expectations held of the individual by the agents affect the experience of sexualities, such as social of socialisation (the family, the educational class,9 ethnicity,10 diverse capabilities11 and age.12 centre, the media and the peer group). Through These factors have a particular impact on adoles- this process of sexual socialisation, individuals cence and youth. During adolescence, the foun- assimilate codes of conduct and normative social dations of affective sexual relationships are and cultural values of quality.24 In addition, sex- acquired and these adolescent experiences will ual socialisation is deeply linked to gender socia- have an impact on later stages of life.13 For this lisation, such that the constructions of reason, it is essential to understand the needs femininity and masculinity are parallel to the con- that adolescents and young people identify with figuration of sexual beliefs, expectations and respect to their sexualities, within the framework desires.7 An individual’s gender trajectories will of sexual and reproductive rights.14 Understanding combine with his or her sexual experiences and what is happening in adolescence will help to determine his or her beliefs and behaviours. develop interventions that guarantee young These will be modulated throughout an individ- people’s positive affective sexual development and ual’s lifetime by the accumulation of positive experience of their sexualities. Existing public pol- and/or negative experiences related to sexuality. icies and services can contribute to the experience of a positive sexuality,15 especially through sex edu- cation, reproductive counselling and contraception, The context of the city of Barcelona prevention and treatment of sexually transmitted Barcelona is a city of 1.6 million inhabitants located infections (STIs), combating sexism and the preven- in Spain, southern Europe, on the Mediterranean tion and treatment and sexual violence.16 Despite coast. The sexual behaviour of youth in Barcelona the recognised importance of psychosocial aspects is well documented through the sexual health infor- in the positive experience of sexuality, the current mation system. Information is collected on the per- dominant model for the study and approach to sex- centage of youth who have had sexual intercourse ualities during youth is biomedical, focused on (at the age of 17 years, 54% of women and 53% of identifying and avoiding risks. men), young people who have used an effective con- At the international level, the effectiveness of traceptive method during their last sexual inter- socio-educational actions, such as counselling or course (83% of women and 89% of men) and on sex education, has been demonstrated through a the use of post-coital contraception (40% of psychosocial paradigm to improve sexual health in women). In Barcelona, only 37% of girls and 32.7% youth.17 Sex education and education for respectful of boys aged 15–19 feel satisfied with their sexual relationships have been shown to be effective in relationships.25 The effect of social determinants of empowering young people to manage their own sexual health, especially gender, has also been risks and improve their sexual health.18,19 Further- studied: there are clear differences in sex-gender more, including a gender perspective can increase patterns with respect to the reasons for first sexual the effectiveness of sex education.20 With regard to relations and inequalities in pregnancy prevention. sexual healthcare services, quality criteria have In addition, in Barcelona, people from 232 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 disadvantaged socioeconomic backgrounds have - What are the sexual needs of youth in Barcelona? worse sexual health indicators,26 LGBTI people - What are the sociodemographic characteristics of have worse indicators of self-perceived health,27 youth using sexual healthcare services? and immigrants from low-income countries have - What barriers do youth experience to making use markedly high abortion rates.28 of sexual health services? As in other similar social contexts, the predomi- nant model of young people’s sexualities is more biomedical than psychosocial. Comprehensive sexu- Methods ality education is not mandatory in Spain. Schools This mixed methods study combined data collec- can decide whether to schedule sex education, tion techniques and quantitative and qualitative and when and how to deliver it. The main public analysis methods to provide more knowledge on sex education programme in Barcelona had a cover- the topics under investigation than would be age of 36% of secondary school students in the gained with separate analyses.31 The relationship 2019–2020 academic year.25 On the other hand, sex- between our research questions, the data collec- ual healthcare services for young people are not tion techniques used and the methods of analysis youth-friendly as a whole, although specialised are shown in Table 1. For each research question, care for young people has been specifically incorpor- a main data collection technique was employed, ated into the portfolio of public sexual healthcare with its corresponding method of analysis. The services29 and there are public services specialised answers to the first and third questions were in youth care. These are called the Tarda Jove, sought through the narratives of young people which consists of a weekly slot reserved for young in the city, whether or not they were users of sex- people in public sexual health centres, and the ual healthcare services. Information from the Centre Jove d’Atenció a les Sexualitats (CJAS), which records of sexual health services was used to specialises in sexual health care for young people. answer the second research question, which aimed to categorise youth accessing the services. Finally, quantitative and qualitative data were The current study interpreted together and conclusions were drawn. Although various interventions have been carried out to improve the sexual health of young people, Qualitative part in Spain, there is no evidence until now as to To answer the first and third research questions, whether these interventions have resolved adoles- we used mainly methods specific to qualitative cents’ and young people’s concerns about their research (Table 1). We designed a qualitative sexuality. We do not know if they can access the study using a socio-constructionist perspective most appropriate, or timely sexual health services that holds that the realities and phenomena to cover their needs. However, it is not our inten- experienced by a person or group of people are tion in this study to conduct a comprehensive embedded in a social and historical context.32 evaluation of any sexual health intervention, as These realities are deeply marked by the unequal these interventions have been widely evaluated distribution of power, rights and resources along in the past few years.30 axes of power. The qualitative part aims to ident- The aim of this research is to understand the ify the barriers faced by young people when narratives of adolescents and young people in Bar- attempting to use public sexual healthcare ser- celona regarding their sexual health from a sexual vices and the needs perceived by these young and reproductive rights perspective. In this regard, people in Barcelona regarding their sexualities our study addresses the research question: “Is the in 2019 (Figure 1). support adolescents and young people receive in Intentional stratified sampling was carried relation to their sexualities adequate?” This ques- out33 with a selection of young people according tion is particularly relevant for policy decision- to gender (male or female), age (14–17; 18–21 or making in Barcelona, establishing the changes 22–24) and country of origin (native or immi- that need to be implemented in interventions grant). Participants were recruited in the waiting and services to suit young people’s needs and rooms of sexual healthcare services. It was agreed determining the resources that should be allo- with the young people whether they wanted to be cated. To answer this question, our study raises interviewed while waiting, when leaving the the three following research questions: clinic, or at another time. Participants who were 233 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 Table 1. Relationship between research questions and study methods Research question 1: Research question 2: What are Research question 3: What are the sexual the sociodemographic What barriers do youth needs of youth in characteristics of youth using have to making use of Barcelona? sexual healthcare services? sexual health services? Contribution of the To understand the To identify the profiles of To identify barriers to the question to the global perceived, normative and youth accessing sexual health availability, access and understanding of the expressed needs of young services and those of young quality of sexual health phenomenon people regarding people excluded from them services sexualities Main data collection Use of triangular groups From the register of users of Use of triangular groups technique and method with young people and sexual healthcare services, a with young people and of analysis used to individual interviews, a descriptive and cross-sectional individual interviews, a answer the question descriptive-interpretative analysis was carried out to descriptive-interpretative analysis was carried out to typify the profiles of youth analysis was carried out to capture the needs using the services identify barriers perceived perceived by the young by the young themselves themselves Strategy for a holistic Based on a convergence matrix in which both the data collected to answer research interpretation of data questions 1, 2 and 3 and the conclusions of the analyses of these questions were and drawing of integrated, an interpretative analysis was again carried out to determine which needs - if conclusions any - of youth’s sexual health are not sufficiently met by public services. Figure 1. Methodological design of this study 234 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 not service users were recruited using a snowball general terms and the young people were invited strategy. The snowball started from the young to share their vision. The interviewer balanced the users, who were asked if they knew of any young people’s participation and cross-examined young people who did not use these services to clarify issues. The person who conducted the who might be interested in participating. The interviews and the triangular groups was an majority of conversations took place in empty con- experienced interviewer who received specific sultation rooms at the health services. However, training for the current study.37 Data were col- some of them were conducted in other public lected from January to April of 2019. spaces where young people could feel A list of the topics covered in the conversations comfortable. is shown in Table 2, including sexualities, sexual Data collection techniques consisted of an indi- health needs, relationships, experiences in ser- vidual interview34 and triangular groups.35 Pre- vices and barriers to the use of services. Both vious studies have previously combined these users and non-users were asked about barriers techniques in the study of sexualities.36 In-depth to access: in users, the ones they had experienced, interviewing was used when the young people and in non-users, the ones they think they would chose to conduct the interview alone, and the tri- face. Narratives were recorded with 50 young angular group when they preferred to be inter- people between the ages of 14 and 24 years. viewed together. In all the triangular groups, the Pre-recording contact lasted about 10 minutes young people already knew each other. In the tri- and included an explanation of the project, the angular groups, the issues were introduced in topics of conversation to be addressed, the Table 2. Guide to talking points for obtaining data from young people in individual interviews and triangular groups Category Subcategory Examples of issues raised Concept of Concept of sex; Concept of sexuality; Concept For you, do the terms sex and sexuality have sexualities of sexual health. the same meaning? For you, what does sexuality include? What do you identify with sexual health? Sexual health Sex education; Risk of pregnancy and STIs; What do you think youth need in terms of needs Reasons for consulting services; Role of the sexuality? How do you rate the sex education internet; Role of pornography. you have received? What concerns do you have about your own sexuality? What would be a reason for you to go to a sexual health service? Relationships and Sexuality and relationships with friends; In your group of friends, is it taboo to talk sexualities Sexuality and affective sexual relationships; about sexuality? What aspects of your Sexuality and family relations. sexuality would you talk about comfortably in a classroom? What sexuality concerns would you share with your mother? Are they the same ones you would talk about with your father? Experiences in Experiences in services Can you identify what you value most highly services and what you would improve in your practice? How did you feel during your time in the practice? Barriers to the use Availability barriers How long did it take you to come to the of services Entry barriers service? How did you learn about the Quality barriers service? 235 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 collection of individual data and the signing of the reason of visit was unavailable for 5,714 (17.8%) informed consent form. Discussions lasted users. between 8 and 33 minutes. The shortest conversa- Explanatory variables were sex (women and tions were conducted while the young people men), age (14–17, 18–21 and 22–24 years), nation- were waiting to be seen. The young people were ality (Spanish, immigrants from high-income invited to participate further after the visit, but countries and those from low-income countries)40 they declined. In these short conversations, the and socioeconomic background (favourable or young people could not be questioned about all unfavourable, depending on whether the avail- the topics and priority was given to delving into able family income in the district of residence one or two topics. Recruitment lasted until data was above or below that of the city as a saturation was achieved. Conversations were tran- whole).41 The second dependent variable was scribed verbatim and completed with a contextua- the reason for consultation. There was no infor- lisation and summaries of the conversations held mation on nationality in 12,537 (39%) users and before and after the recording. none on socioeconomic background in 15,065 A descriptive-interpretative analysis of the nar- (47%). ratives was carried out through a sociological dis- A descriptive statistical analysis was carried out course analysis.38 The process of category on the use of public sexual healthcare services in generation was mostly inductive, performed with Barcelona by young people. Measures of the cov- the help of Atlas.Ti software. The researchers indi- erage of services use were obtained according to vidually performed the repeated reading of the variables (sex, age, nationality, socioeconomic texts, as well as the coding and analysis of the dis- background), taking the young population of Bar- course, and the points of view were triangulated. celona as the denominator. The analysis was car- An explanatory framework was developed, and ried out with the STATA v12 software. summaries of the analyses were produced. Ethical concerns Quantitative part The study was approved by the Clinical Research To answer the second research question, we Ethics Committee of Parc de Salut Mar (approval mainly used quantitative research methods number CEIm-PSMAR 2020/9354) on 1 February (Figure 1). A descriptive, cross-sectional analysis 2021. The study was explained to participants was carried out. The study population was the before informed consent was obtained, it was 32,161 users of Barcelona’s public sexual health- emphasised that they would be free to answer care services, aged 14–24, between 2015 and questions or not, and the confidentiality of the 2017. Using the registers of visits from the public conversations held was stressed. sexual healthcare system centres as a source, the sociodemographic profiles of users were cate- gorised from their first visits. These profiles were Results compared with the young population of the city Responses from 50 young people (35 girls and 15 as a whole based on information from the 2016 boys) were analysed. The mean age of participants municipal census, provided by the City Council was 18.1 years (range 14–24). Most participants itself.39 were from disadvantaged socioeconomic back- The dependent variable of our analysis was ser- grounds (n = 32). The majority had normative sex- vices use, operationalised as the first visit made by ualities (n = 41) and were native (n = 36). persons aged between 14 and 24 years to a public Key themes identified during the analysis are sexual healthcare service in the city of Barcelona explored below. between 2015 and 2017. The reasons for visits were grouped into 10 categories: (a) sexuality Perceived needs of youth regarding their care for non-medical sexuality concerns, (b) sexuality psychological counselling, (c) non-communicable Young people declared they had a positive experi- diseases, (d) sexually transmitted infections, (e) ence and view of sexuality and enjoyed it. They reproductive counselling, (f) pregnancy testing, also considered they had good sexual health. (g) post-coital contraception, (h) abortion request, They identified three needs related to their sexual (i) pregnancy and postpartum care, (j) other and health (Figure 2). First, they needed knowledge non-relevant consultations. Information for and information about sexuality, appropriate to 236 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 Figure 2. Narrative configurations of young people’s discourse their diverse contexts and experiences. This infor- “You can’t really ask in class what you like, can mation could be drawn from both formal and you? Because maybe you’re also afraid of being informal contexts. Secondly, they reported they told something later.” (Man, 16 years) wanted to live a sexuality free of sexist attitudes Among young people who had had some formal and behaviours. Thirdly, youth stated they needed sex education, there was general agreement that strategies for the management of unexpected situ- its contents consisted of moralistic talks focusing ations. Although all young people mentioned on the risks of heterosexual sexual relations, these three needs consecutively, the narrative especially the need to use condoms for pregnancy configurations of their discourse were strongly prevention. Young people with dissident sexuali- influenced by age and gender. ties reported that the formal sexual education received was not adapted to sexual and gender diversity in sexually transmitted infection (STI) Formal sex education prevention. All the young people considered sex education in the school context was essential to have the infor- “When you talk about having relationships with mation and knowledge necessary to make protection and all these things, I think people decisions on their own sexuality. None of the focus on heterosexual relationships and not young people were satisfied with the formal sex getting pregnant. […] There are also diseases education they had received, and many pointed and sometimes they are not given their real out that informal sex education had a stronger importance.” (Man, 23 years, dissident influence (Figure 2). Young people reported that sexuality) they either had no or little sex education, and Young people stated that there were taboos that 14- and 17-year-olds and young women especially needed to be addressed. Knowledge of one’s were left with doubts. own body, pleasure and intercourse were not mentioned in sex education, except in highly “When they do it [sex education], they do it too late, valued exceptions. In general, informants con- and they do it very little, very badly. I mean, every- sidered that the sexuality education they had thing they’ve taught to us about sex education is the received did not discuss consent, sexist beha- craziest thing I’ve ever seen in my life.” (Woman, 23 viours and attitudes, violence against women in years) relationships, or the myths of romantic love. For youth, formal sex education should be partici- Women reported speaking more about sexuality patory and imparted in small groups. Young infor- and the female body and, especially those mants of both sexes indicated that sex education older than 18 years, believed taboos needed to should be provided by people they trust and be broken about female masturbation and with whom they felt safe. menstruation: 237 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 “If you have to have four assholes [boys] there, themselves to be an exception and that they per- taunting you that ‘you’ve got your period!’, and sonally had not been influenced by it: you’re ashamed to [get a friend to] pass [you] a “I don’t think it has any influence on the way I have tampon … I don’t know, I wish that could be chan- sex, or anything, or how I experience it. Because it’s ged.” (Woman, 18 years) accepted that it’s unrealistic. For me it’s entertain- ment, as if I were watching a series.” (Man, 17 years) Informal sex education According to informants, conversations about Young people recognised that family, internet and sexuality among peers were segregated by gender pornography, as well as their peers (Figure 2) and, regardless of age, only took place within the played a key role in providing information about most intimate friendships. Women exchanged sexuality, as they allowed them to resolve doubts secrets and intimacy as well as concerns and pro- that formal sex education had not addressed. blems. Menstruation and masturbation were Informants believed that their family did not taboo, and some considered it unhygienic: play an important role in their sex education. They distinguished between the paternal and “It was embarrassing, and we dealt our pads in maternal roles: the father played no role and class as a drug. Like, you know, don’t let anyone the mother was the person to turn to as a last see it, sneaky.” (Woman, 19 years) resort. Most young people stated they had “A girl says: I’ve jerked and everyone [her friends]: searched the Internet for information on sexu- ‘oh, gross’, ‘what are you saying’, I mean, ‘you’ve ality, such as the appearance of the genitals, sex- fingered your... you know?’” (Woman, 15 years) ual positions, the G-spot and contraceptive methods. A few men stated that their personal Among men, friends served to reflect back and experience was enough for them, and they had demonstrate virility. This was true for both hetero- never searched the Internet. Young people said sexual and non-heterosexual men. Topics evolved they had had doubts about the reliability of the with age. Younger men reported they discussed pages consulted, looked for sites validated by the number of times they masturbated, while institutions and avoided forums: older men reported they commented on who they masturbated with and on how and where “There are situations where you say … you’re they had sex. However, men stated that they did embarrassed to ask, you know? So, it’s easier to not reveal certain aspects of their sexual encoun- find, although what you can find on the internet ters that were considered as strictly private. can be very relative. You may not be able to find the information you’re looking for, or you may be “[Who I fuck] That’s right, you tell your good friends. given the wrong information.” (Man, 23 years) But, for example, if I left here with a wart or … I don’t know, syphilis or that candidiasis, I might Few women reported they had viewed pornogra- not tell many people.” (Man, 18 years) phy. They mentioned that they had been alarmed that people could be sexually excited by content Sexist behaviours occurred both during and that they described as violent, vulgar, sexist and outside sexual relations. Women said that for misogynistic. They said it fostered a culture of men the central practice was penetration and rape and was intended for individual male plea- they put their pleasure before that of their sure. They said they were concerned that the partners. issue of consent did not appear. “They’re fucking and he takes off the condom, the “There are so many things that porn instils in you. girl tells him to stop but he keeps going on. This It’s sexist, rape. It’s totally … I was shocked.” happens, and a lot.” (Woman, 19 years) (Woman, 18 years) Women described the sexist behaviours, both In contrast, many men reported having viewed psychological and sexual, exerted by men through pornography from a very early age, for entertain- control and emotional blackmail, which under- ment and pleasure, and perhaps to learn about mined the women’s self-esteem. Virtually all the sexual practices and positions. They agreed with women participating in the study, regardless of women that pornography influenced men’s sexual their age, had experienced this phenomenon at expectations and practices, although all believed first hand. 238 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 “What abounds is psychological abuse, especially around 2–3% in all age groups. We found dispa- between couples. In other words, yes, making the rate percentages in some age groups between other person feel bad. Jealousy could be an aspect socioeconomic backgrounds: post-coital contra- of psychological abuse. […] That you can’t do any- ception visits were significantly higher in young thing but spend time with that person, that you people from advantaged socioeconomic back- can’t go out or go about your life. They make you grounds (15%) compared to disadvantaged (6%), feel bad, they make you feel inferior. […] The and this difference increased in the 14–17 age relationship can turn into one person being in group (33% in advantaged, 15% in disadvan- charge and the other obeying. And you don’t even taged). On the other hand, the request for abor- realise it.” (Woman, 18 years) tion was slightly higher in young people from disadvantaged backgrounds, although this differ- However, no particular man reported that he con- ence was not significant. In the 14–17 age sidered himself to be sexist. Nor did any man group, users from advantaged backgrounds admit a sexist attitude or behaviour on his part. were less likely to seek reproductive advice “There are macho attitudes, actions. I think there is (16%) than those from disadvantaged back- this, but there are no machista people.” (Man, 24 grounds (25%), but there was no difference in years) other age groups. The most frequent reason for consultation among men was related to STI (52%), as seen in Use of services Figure 3(b). The percentage of visits for STIs Of 14–24–year-olds, 32,161 (21%) used public increased with age: 20% in ages 14–17, 51% in sexual healthcare services in Barcelona between ages 18–21 and 71% in ages 22–24. In the 14–17 2015 and 2017. Of these, the majority were age group, the main reason for their visit was women (95%), aged 18–21 years (52%), of Spanish post-coital contraception (24%). This percentage nationality (69%) and disadvantaged socioeco- differed according to socioeconomic background, nomic backgrounds (72%) compared with the being 33% in advantaged and 15% in disadvan- total number of users (Table 3). Services had taged backgrounds. 40% coverage in women, compared with 2% in men (p < 0.01). Young people aged 18–21 years Access to sexual healthcare services and were over-represented (p < 0.01). There were barriers identified no differences in nationality between the gen- Young people needed services to support them in eral population and services users. Significant coping with the circumstances that could arise, differences were found in socioeconomic back- which varied according to gender and age, and ground of public sexual health service users were related to the reasons for consulting the ser- according to sex (p = 0.03): women from disad- vices. Among female informants, especially girls vantaged backgrounds were slightly over-rep- aged 14–17 years, these circumstances lay in resented while men from advantaged reproductive health: demand for free contracep- backgrounds were over-represented. tives, menstruation, pregnancy testing, post-coital The reasons for consultation differed by sex, contraception and abortion. Among male infor- age and socioeconomic background (Figure 3 mants, concerns were related to difficulties in (a)). Women attended mainly for reasons related intercourse: erection problems, premature ejacu- to non-communicable diseases (30%) and repro- lation and difficulties with condom use. Men ductive counselling (23%). By age group, women aged between 22 and 24 years were especially aged 14–17 stood out for the percentage of visits concerned about STIs, regardless of their sexual for post-coital contraception (24%), which orientation, although they reported they knew dropped in the other groups (9% in 18–21 and how to protect themselves. In women with dissi- 4% in 22-24). Visits for sexual transmitted infec- dent sexualities aged 22–24, STIs were also a tions (STI) and delivery and postpartum care main concern. These women indicated that they increased progressively with age: 4%, 9% and were not satisfied with the preventive strategies 13% for STI, 2%, 6% and 8% for delivery and they were aware of. postpartum care. In contrast, requests for preg- However, there were barriers to accessing ser- nancy tests decreased with age by 11%, 9% and vices (Figure 2). Some informants did not know 5%. Visits for abortion remained stable at where to go, especially those aged 14–17 years. 239 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 Table 3. Youth aged 14–24 years using public sexual healthcare services. Barcelona City, 2015–2017 Women Men a Users Population % Coverage Users Populationa % Coverage over 3 years over 3 years N % N % (2015–2017) N % N % (2015–2017) Barcelona 30,693 76,202 40.3% 1,467 78,541 1.9% Age (years) 14–17 7,761 25.3% 25,025 32.8% 31.0% 306 20.9% 26,377 33.6% 1.2% 18–21 15,990 52.1% 26,314 34.5% 60.8% 680 46.4% 27,837 35.4% 2.4% 22–24 6,940 22.6% 24,863 32.6% 27.9% 481 32.8% 24,327 31.0% 2.0% No data 2 N/A 0 N/A Origin Spanish 12,777 69.0% 53,856 70.7% N/Ab 848 76.6% 55,901 71.2% N/Ab High-income 1,031 5.6% 5,431 7.1% N/Ab 57 5.1% 4,669 5.9% N/Ab countries Low-income 4,708 25.4% 16,915 22.2% N/Ab 202 18.2% 17,971 22.9% N/Ab countries No data 12,177 N/A 360 N/A Socioeconomic background Advantaged 4,445 26.9% 29,955 39.3% N/Ab 289 49.1% 29,706 37.8% N/Ab Disadvantaged 12,061 73.1% 46,247 60.7% N/Ab 300 50.9% 48,835 62.2% N/Ab No data 14,187 N/A 878 N/A a Population refers to young people registered in Barcelona’s City Census in 2016. b Estimates of coverage could not be computed due to high levels of missing data. They admitted that they were not well informed private sector. Many of them said they did not and that their knowledge was garnered through know about abortion procedures. Women, in par- friendships. If they needed post-coital contracep- ticular younger ones, reported that this was a tion or a pregnancy test, many women would pre- cause of concern. fer to go to a pharmacy rather than a sexual healthcare centre. With the exception of some “Typical of a period delay, what do you think: Shit, women between the ages of 22 and 24 years, what if I got pregnant for whatever? What the fuck most were unaware of their abortion rights: do I do now? I would have liked someone to have although they would go to a health centre, they explained it to me, what you have to do. And did not know that it is free. Women from advan- what solution is there? Because I don’t know, if taged socioeconomic backgrounds said they there’s a pill or if they really have to put something would prefer to undergo an abortion in the in there. I don’t know.” (Woman, 18 years) 240 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 Figure 3. Reasons for consultation reported by young people between the ages of 14 and 24 years using public sexual healthcare services. Barcelona, 2015–2017. (a) Women, (b) Men 241 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 The barriers of access to sexual healthcare services experiences very positively, although their initial were grouped in: availability barriers, entry bar- expectations were low. Young people liked the riers and quality barriers (Figure 2). fact that the service was free, that they had enough time to resolve their doubts and that Barriers to availability their waiting times for a further consultation The main barrier was opening hours: young were relatively short. The treatment received, people reported they were concerned about the characterised by empathy, active listening and management of emergencies arising on weekends respect, was rated highly. For example, they said or evenings. They placed a high value on services they appreciated that any procedures being car- being close to their place of residence. They also ried out were explained and that the health pro- reported they attached importance to being able fessionals did not make assumptions about their to drop in without an appointment. Many young sexuality and asked if the companion is a friend people, especially 14–17-year-olds and men, men- or partner, whatever the sex. Young people tioned they were unaware of the existence of ser- reported that specialised youth care solved their vices, consultation procedures and appropriate concerns. reasons for attendance. They pointed to sex edu- “I got there and I said [to the professional]: well, I’ll cation as an opportunity to advertise these ser- start from scratch because I have no idea, and I vices and stressed the importance of keeping want you to explain everything to me. […] I felt websites up to date and with easily accessible super comfortable, and the treatment I received information. was … wow! I mean, I got out of there very “I have no idea if I have to go to the gynaecologist. happy. I wasn’t even ashamed to ask her for a preg- Where to go to the gynaecologist, how to ask for an nancy test. I wasn’t going to, but I felt so comforta- appointment. Like … in the normal health centre, ble that I asked her and she told me to do it right right?” (Woman, 17 years) there, to go to the bathroom and we would look at it together.” (Woman, 18 years) Accessibility and acceptability barriers In contrast, experiences in public gynaecological Young people described that they were embar- services were repeatedly reported as negative. rassed to share their concerns about sexuality. Young informants said they felt judged by gynae- They said it was, therefore, very uncomfortable for cologists, who dismissed their concerns, did not them to discuss the reason for consultation at the empathise with them and treated them paterna- reception desk. In the waiting room, they were listically. Young people attributed many of their stressed by long waits and by both sepulchral silence complaints to gynaecologists, while they valued and commotion. In addition, women repeatedly the work of midwives positively. mentioned that they felt judged by adults if the wait- “I went to ask her to explain to me what contracep- ing rooms were shared, especially the younger ones. tive methods there are. In other words, different They reported meeting known peers in the waiting from condoms. I wanted information and, of room was not a problem for them, as there was course, [the gynaecologist] asked me why, and I shared understanding. In the consultation, the told her that, that many times I had had sex with- young people declared they assumed they would out a condom. And I don’t know, I felt a little bad not be judged and trusted that confidentiality because … I don’t know, I think she judged me a would be respected. Throughout the visit, young lot for that and she was very unpleasant all the people said the main concern for them was that time. And she didn’t give me that much information their parents did not learn of their attendance, either. […] I left there thinking that I would never especially in the case of women aged 14–17 years: go back to a gynaecologist again.” (Woman, 19 “You leave your name, but that’s it. You don’t have years) to tell your parents or do anything. So I think your privacy is very much respected.” (Woman, 17 years) Discussion Quality barriers In this study, we used quantitative and qualitative In the public services specialised in the sexual methods to explore the sexual health needs of health care of young people, users rated their young people in Barcelona. Young people need 242 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 sufficient information to allow decision-making, knowledge of the body, pleasure and emotion to experience their sexuality pleasurably and management. It is also necessary to break down free of sexist attitudes and behaviours, and to the myths about sexuality and romantic love.36 have the resources to manage situations satisfac- Some of the reasons that would explain this inco- torily, like knowing how to respond in the event herence, in addition to the lack of political will, of encountering a possible unwanted pregnancy could be the lack of specialised professionals to or STI. These needs correspond to sexual and provide sex education from non-biomedical per- reproductive rights3 and, therefore, the barriers spectives in Spain,42 or a hypothetical fear of the and shortfalls detected in our study represent a objections that might be raised by some families, violation of young people’s sexual rights in teachers and educational centres if sex and plea- Barcelona. sure were discussed explicitly in the classroom To address these needs in accordance with without adequate legal regulation.43 young people’s views, two complementary inter- Approaches to delivering sex education also ventions are required: formal sex education and need to be reviewed. Although the most effective sexual healthcare services. In these two interven- and highly rated interventions applied participa- tions, it is essential to incorporate the gender per- tory and experiential methods, it should be spective in a comprehensive manner and to raise remembered that school classrooms are not awareness of the need to eradicate sexist attitudes always safe spaces.44 Sexist attitudes and struc- and behaviours. tural LGBTI-phobia inhibit young people, who reported they preferred to remain in doubt rather Relationship between the need for than be exposed to harmful comments from the information and formal sex education group. An effective means of correcting this situ- interventions ation is to normalise existing sexual and gender Although the information is one of the main diversity.45 requirements for sexual health, young people sta- We recommend that the Spanish government ted they had little information about sexuality, introduce sex education into the mandatory curri- irrespective of whether they had participated in culum at all stages of education in schools nation- any sex education programme or not. Those wide, as part of a holistic sexual health strategy for youth that had received sex education described young people. Meanwhile, in Barcelona, a socio- it as scarce, too risk-centred, heteronormative educational intervention to promote healthy and and coito-centric. When young people did not equitable relationships should be designed find answers to their concerns in formal sex edu- which must necessarily have a gender perspec- cation, they resorted to informal contexts, with tive.20 This should go beyond the biomedical the consequent spread of myths and rumours. model and address gender-based violence and Formal sex education interventions have been sexual and reproductive rights.18,19 shown to be effective in improving sexual health and in preventing sexism in affective sexual Relationship between the need to manage relations.16 However, most international studies situations and sexual healthcare services indicate that sex education does not really exist The young participants in our study identified in Spain.41 Sex education has not yet been manda- public sexual healthcare services as a place to go torily included in the school curriculum and no in case of need. Sexual health care has been national guide has been published by the govern- shown to be effective in preventing sexual health ment. In Barcelona, despite attempts to include problems.46 However, we offer the following three formal sex education programmes in schools, reflections. they are carried out on an ad hoc basis and have First, our results show that there are three gaps unequal coverage. The main formal sex education in public service coverage: men; women from programme has 36% coverage and consists of six advantaged socioeconomic backgrounds; and one-hour sessions.25 Although the content has the 14–17-year-old age range. The under-rep- been recently diversified in order to include resentation of men should be understood in the LGBTI sexualities, it is still largely focused on context of the patriarchal system, which makes risks and how to avoid them. women responsible for sexual health. However, This contrasts with the established criteria,19 the percentage of users in Barcelona (5%) is which propose focusing interventions on much lower than for Europe as a whole, where 243 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 men account for 25% of users.47 Some strategies appreciate, above all, rapport with health pro- that could increase the percentage of men seeking fessionals,54 and the perception of services as services would be making them equally respon- safe spaces where they can open up and find sible for sexual health through sex education answers to their questions due to fast, free, interventions with a gender perspective.48 Invol- person-centred care. Unlike other studies, in ving men in service design and communication which young women did not want their peers strategies could reduce acceptability barriers. to know that they were using services,22 in our The scarce presence of women from favoured study, the concept of privacy generally related socioeconomic backgrounds contrasts with the to parents not being aware of the content of the situation elsewhere, where the cost of services consultations, and young people in Barcelona can become one of the main barriers to access trusted that their confidentiality would not be for young people from disadvantaged back- breached. grounds.49 In Barcelona, where free public ser- We propose the expansion of the youth-friendly vices coexist with private services, the under- sexual healthcare model as part of the sexual representation of women from favoured back- health strategy for young people. This involves grounds may be linked to the use of private gynae- training all personnel who work in youth sexuality cological services, as can be seen from the and ensuring comfortable and safe spaces. Sexual interviews with young people from these more health care for men needs to be urgently advantaged backgrounds. Low service coverage addressed. On the other hand, the information among 14- to 17-year-olds may be related to a system that collects data from young people lack of knowledge of services and lack of privacy. should be improved, as it currently has a very Our results agree with those of other studies that high percentage of missing data. Furthermore, have previously reported that young people were this would allow more in-depth analyses of the discouraged from attending services if they use of services by young people of nationalities required family authorisation50 or doubted their other than Spanish and with dissident sexualities, confidentiality.51 for whom there is currently no information. The second reflection relates to the reasons for using public sexual health services. Quantitative Strengths and limitations of the study data show that women attend mostly for reasons Limitations of the present study include the use of related to contraception while men do so for visit records as an information source, with many STIs and difficulties in intercourse. Although missing data on the nationality of persons receiv- these findings were reflected to some extent in ing assistance: this does not allow the exploration the qualitative data, during conversations, men of associations and correlations in quantitative found it harder to admit to difficulties, as doing analysis. In addition, the availability of data exclu- so would mean questioning their virility,52 and sively from public services may imply a selection women found it easier to attend services when bias in relation to the socioeconomic backgrounds the reason was reproductive health than when it of the people included in the study. The compo- concerned their sexual health. However, although sition of the sample in the qualitative analysis young people did not attend consultations for was not intended to be statistically representative information on sexual pleasure, they were con- but rather to be socially representative. Finally, cerned about the issue, as shown by the fact the type of study carried out did not allow us to that, on the institutional website of the services, extrapolate what happens in other contexts, the most frequently visited sections are those such as smaller municipalities or those in non- related to pleasure and sexuality.53 urban contexts with fewer services. A third reflection is that, in our study, all young The main strength of the study is that, due to users of public sexual healthcare services special- the use of mixed methods, quantitative and quali- ised in young people rated these services posi- tative data were integrated to offer results that tively; while users of services not specialised in help to deepen knowledge of the sexual health young people, such as gynaecological care, were needs of young people and to identify those not almost always rated poorly. This may be because being covered. While discourse saturation was specialised services, unlike gynaecological care, sought for the objectives of the study, we were fit perfectly the criteria established by the WHO also able to delve deeper into aspects such as for youth-friendly services.21 Young people the role of pornography, the role of parents and 244 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 men’s access to services. In addition, two aspects and Karina Gayoso (Centre Jove d’Atenció a les Sex- of sexual health appear in this work that, although ualitats), Alicia Carrascón, Judit Pelegrí, Laia Agui- complementary, are usually studied separately: lar, Irene Domínguez and Lara Beatriz Martin sexual education and sexual health care. By incor- (ASSIR Esquerra, CAP Numància) and Anna Zara- porating both aspects, this study allows us to goza and Rosa Adell (ASSIR Muntanya, CAP Rio de obtain a global vision of the phenomenon. Janeiro). The authors thank Gail Craigie for the criti- cal reading and editing of this paper. Conclusions Disclosure statement Youth positively rated the public sexual health- No potential conflict of interest was reported by the care services specialising in young people in the author(s). city of Barcelona and wanted this to be the model, in line with proposals in international Funding guidelines. Sex education for young people is par- tially covered by interventions in public schools This work was supported in part by Carlos III Health but is insufficient: quality sex education should Institute as intermediate from FEDER and FSE in the be imparted by trained personnel and introduced multicentric project “Promoción de activos protec- in the curriculum at all stages of compulsory edu- tores de la violencia de género en la adolescencia cation. Sex education and sexual healthcare ser- y pre–adolescencia” (2019–2021) (project reference vices should be approached as part of a single PI18/00544). The Institute has only acted in a fund- strategy: comprehensive sexual health policies. ing capacity, with no influence on the outcomes of Furthermore, given that experiences of sexualities said research. This work is part of Lluís Forcadell– are gender-specific, it is essential to incorporate Díez’s doctoral thesis, which is being carried out feminist and sexual affective diversity perspectives in the Departament de Ciències Experimentals i de to all matters related to the sexuality of young la Salut at Universitat Pompeu Fabra, Barcelona, people. Spain. Acknowledgements ORCID The work has been made possible thanks to the Lluís Forcadell-Díez http://orcid.org/0000-0002- involvement of Enriqueta Pujol, as well as Mari 3934-4666 Paz Oliver, Raquel Gómez, Sílvia Egea, Erika Ros, Gloria Pérez http://orcid.org/0000-0001-6653- Georgina Picas, Maria Ferrero Barrio, Jacque Segura 3393 References 1. Foucault M. Histoire de la sexualité 1: La volonté de savoir. (9826):1641–1652. 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DOI:10.1016/J. and strategies for sustaining youth-friendly health EDUREV.2017.10.002. services – a qualitative study from the perspective of 46. Anderson JE, Lowen CA. Connecting youth with health professionals at youth clinics in northern Sweden. services: systematic review. Can Fam Phys. 2010;56 Reprod Health. 2016;13(1):147. DOI:10.1186/s12978- (8):778–784. 016-0261-6. Résumé Resumen Une expérience positive de la sexualité pendant la Una experiencia positiva de sexualidad durante la jeunesse est déterminante pour une bonne santé juventud es clave para una buena salud sexual sexuelle plus tard dans la vie. Il est donc essentiel más adelante en la vida. Por consiguiente, es de répondre aux besoins de santé sexuelle des esencial atender las necesidades de salud sexual jeunes et à leurs droits sexuels et reproductifs. y derechos sexuales y reproductivos de las perso- Cette étude visait à identifier les besoins de nas jóvenes. El objetivo de este estudio era identi- santé sexuelle non satisfaits parmi les jeunes ficar las necesidades no satisfechas de salud dans la ville de Barcelone (Espagne) au moyen sexual de jóvenes en la ciudad de Barcelona d’une recherche à méthodes mixtes. Nous avons (España) por medio de la investigación de méto- analysé les récits de jeunes (n = 50) âgés de 14 à dos mixtos. Analizamos las narrativas de jóvenes 24 ans de différents genres, origines, sexualités (n = 50) de 14 a 24 años con diferentes géneros, et milieux socioéconomiques, recueillis de janvier orígenes, sexualidades y condiciones socioeconó- à avril 2019. Une analyse statistique descriptive a micas, recolectadas entre enero y abril de 2019. aussi été réalisé sur les dossiers des visites aux ser- Además, se realizó un análisis estadístico descrip- vices de santé sexuelle et les raisons de la tivo de los registros de consultas a servicios de 247 L. Forcadell-Díez et al. Sexual and Reproductive Health Matters 2022;30(1):231–248 consultation. Nous avons constaté que 32 161 salud sexual y las razones para la consulta. Encon- (21%) jeunes, âgés de 14 à 24 ans, avaient utilisé tramos que 32,161 (21%) jóvenes, de 14 a 24 años, des services de soins de santé sexuelle à Barcelone habían usado servicios de salud sexual en Barce- entre 2015 et 2017, alors que les raisons de la con- lona entre 2015 y 2017, mientras que los motivos sultation variaient selon le sexe, le genre et l’en- para las consultas difirieron entre sexos, géneros y vironnement socioéconomique. Les jeunes ont condiciones socioeconómicas. Las personas déclaré qu’ils avaient besoin de davantage d’infor- jóvenes declararon que necesitaban más informa- mations pour jouir de leur sexualité, pour savoir ción para disfrutar su sexualidad, para saber a où aller en cas de situation inattendue et pour dónde ir en caso de una situación inesperada y apprendre comment combattre les violences sex- para aprender a combatir la violencia de género. istes. Ils ont affirmé que l’éducation à la sexualité Dijeron que la educación en sexualidad que qu’ils avaient reçue était insuffisante et axée sur habían recibido era escasa y centrada en riesgos. les risques. Nous avons observé que l’éducation Encontramos que la educación sexual formal es sexuelle formelle est lacunaire et que l’éducation escasa, por lo cual la educación sexual informal sexuelle informelle assumait donc un rôle majeur. adquiere el rol principal. Los servicios actuales Les services actuels peuvent être améliorés en pueden mejorarse ampliando la cobertura, capa- élargissant la couverture, en formant des profes- citando a profesionales y reduciendo las barreras sionnels et en réduisant les obstacles à l’accept- de aceptabilidad y accesibilidad. El sexismo es abilité et l’accessibilité. Le sexisme est ubicuo en las relaciones sexuales, románticas y omniprésent dans les rapports sexuels, les fré- personales de la juventud. Recomendamos plani- quentations et les relations personnelles. Nous ficar los servicios de salud sexual y educación sex- recommandons de planifier des services de soins ual formal, en los que se incorpore una sólida de santé sexuelle et une éducation sexuelle for- estrategia de género como parte de la misma melle dans laquelle une solide stratégie de estrategia. genre sera intégrée, comme élément de la même stratégie. 248