Master Thesis

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Graduate School of Communication Master programme Communication Science

Persuasive Communication

Master Thesis

“You can’t catch Chlamydia from the air”:

A qualitative exploration of sexual health education in The Netherlands

Student: Aline Lefèvre Student number: 11368144 Supervisor: Dr. Gian-Louis Hernandez

Date: 23rd of June 2022

Word count (approved by supervisor): 9106 words

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Abstract

Background: Sexual health is fundamental to people’s well-being, yet sexual health statistics in the Netherlands still show concerning rates of unsafe and unwanted sexual behaviour.

While the Dutch school sexual health education system is praised for its quality, students are not satisfied and often turn to the Internet as their main source of sexual health information.

But online searching also has its challenges of quality and safety.

Objective: The aim of this study was to explore how young people in the Netherlands experienced their school sexual health education classes, and to understand their online searching habits and their needs for online content on sexual health.

Method: This research employed the qualitative method and nine interviews were conducted online in the last two weeks of May 2022. The participants were recruited through purposive sampling and ranged between 19 and 24 years old. Data analysis was conducted with the Atlas.ti online tool and 366 codes were extracted from the open-coding procedure.

Results: Participants highlighted problems with the sexual education curriculum in school, raising issues such as heteronormativity, the curriculum being too biology-focused, and the classroom not being a safe space to discuss sexuality. Most participants rely on the Internet as their main source of sexual health information and systematically engage in source and fact- checking to assess the quality of information. Participants proposed suggestions for an online source which would be easy to navigate and present information in a digestible size, written by experts.

Conclusion: This study finds that youth in the Netherlands is not satisfied with the sexual health education they received in school and often rely on the Internet as a main source of information. This research highlights the importance of providing safe and reliable

information online, and tailoring both school sexual health education and online information to the content that youth are interested in.

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Introduction

“Intercourse can be wonderful, but it can also cause tremendous pain. And if you're not careful, sex can destroy lives” (Jean Milburn, Sex Education). This quote comes from the Netflix show Sex Education (Nunn et al., 2019) the main goal of which is to highlight the importance of comprehensive sexuality education (CSE). CSE is defined as ‘an approach that seeks to equip young people with the knowledge, skills, attitudes and values they need to determine and enjoy their sexuality—physically and emotionally, individually and in relationships’ (Guttmacher Institute, n.d.). Ultimately, the goal of sexuality education is to teach and promote sexual health. The conceptualisation of sexual health in this research was based on the World Health Organisation’s (WHO) working definition of sexual health:

“A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” (World Health Organisation, n.d.)

Nevertheless, progress in developing strong sexual health education is often overshadowed by politics, the economy, social norms and values (i.e., discrimination and gender inequality), and an overall lack of openness to address issues related to sexuality (Starrs et al., 2018). The Guttmacher-Lancet Commission reported in 2018 that over the course of their lives, almost all of the 4.3 billion individuals of reproductive age worldwide will experience inadequate sexual and reproductive health services (Starrs et al., 2018).

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This study was conducted in the Netherlands and the focus of this research was to gain a more thorough understanding of young people’s needs for sexual health information, their scepticism when searching for online sexual health information, and their sexual health literacy. The goal was to lead the way for appropriate and approachable online sexual health information to young people in the Netherlands.

Often, not all the elements cited in the definition of sexual health are present in schools’ sexuality education curricula. In this regard, the Dutch sexuality education system has been described as an internationally exemplary curriculum (Krebbekx, 2020).

Nevertheless, it lacks the aforementioned elements. At present, sexuality education in the Netherlands still mainly relies on a biology framework, addressing topics such as puberty, sexual reproduction and unwanted pregnancies, as well as prevention of sexually transmitted diseases (STDs). In addition, it takes place between 13 and 15 years old when all pupils are still enrolled in biology lessons (Cense et al., 2020). Students in the Netherlands rated this type of sexuality education as mediocre (5.8 out of 10), and even more so for LGBTQIA+

students who gave it an average rate of 5.2 out of 10 (Cense et al., 2020). Next to this low rating of sexuality education in schools, young people in the Netherlands have an increasing tendency to turn to online media to learn about sex (Nikkelen et al., 2020).

Online sexual information seeking is quick, anonymous and easily accessible, with a large variety of sources and perspectives (Nikkelen et al., 2020). This information-seeking method is particularly common among minorities such as LGBTQIA+ students due to fears of prejudice, to the often-heterosexual viewpoint of formal sexual education, as well as to the lack of appropriate content in formal education and healthcare services (Farrugia et al., 2021).

Additionally, Flanders et al. (2021) discovered a relationship between the need for online sexual health information seeking and the amount of sexual health information a person is exposed to in the offline environment (e.g. school, peers, family).

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However, the Internet is a central source for misinformation, and scepticism is

growing (Farrugia et al., 2021). Online sources of information are diversified and include both scientific and factual content from official sources (e.g. government websites, official

healthcare websites), as well as experiential and opinion-based content from user-generated content (UGC). Farrugia et al. (2021) state that students tend to prefer official or science- based websites with citations at the end and, for instance, .org, .gov websites. Students trust these scientific sources more, however, even on those websites, Farrugia et al. 's (2021) research participants tended to approach the information critically. Some participants even reported being more sceptical of official or authoritative sources than resources informed by personal experiences. When choosing a preferred source of information, there was a

distinction between factual information (physical health, sexually transmitted infections, etc.) and subjective information such as relationships, consent, etc. (Farrugia et al., 2021).

Similarly, audio-visual content such as pornography is also a popular learning tool used to seek information about sexuality and sexual relationships (Krahé et al., 2021). In their recent study, Krahé et al. (2021) identified pornography realism (i.e. frequency of use and perception as realistic) as a predictor of risky sexual scripts, risky sexual behaviour, and acceptance of sexual coercion. Overall, Fraser et al., (2020) described how youth struggle to find relevant and reliable relationships and sexual health information, and consequently engage in

extensive and complex processes of research and synthesis to generate their own knowledge base. These authors identified three steps: distinguishing between fact and opinion or

experience, synthesising different sources, and establishing hierarchies of expertise (Fraser et al., 2021).

Yet, to achieve this critical approach to sexual health information, young people must be equipped with a certain level of health literacy. Health literacy helps individuals achieving cognitive skills and improves involvement in health promotion and preventive behaviour

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(Rakhshaee et al., 2020). The World Health Organisation stated that sexual health literacy equips people with the ability to understand and apply health information, which leads to various health benefits (Rakhshaee et al., 2020). Moreover, a lack of sexual health literacy is associated with many sexual problems subsequent to wrong beliefs about sexual relationships (Rakhshaee et al., 2020). Thus, for this research, sexual health literacy is conceptualised as

‘an individual’s knowledge, beliefs, attitudes, motivations and skills in accessing,

understanding, evaluating and applying sexual health information in social, sexual, online and healthcare contexts, to negotiate and make judgements and decisions concerning sexual healthcare, health promotion, relationships and well-being’ (Martins, 2017).

Finally, there were two main gaps in the literature. Firstly, recent literature about the current status of sexual health education in the Netherland is limited. Between 2012 and 2017, the Long Live Love+ programme, a large school-based online intervention in the Netherlands, aimed to improve sexual health education in school. Through this programme, healthy

relationships (free of coercion), pregnancy and STI prevention, and prejudice towards sexual minorities were addressed (Mevissen et al., 2017). However, the sexual health education evaluations revealed by Cense et al.’s (2020) suggest that this intervention was not sufficient.

Nevertheless, after 2018, this topic seems to have been less prominent in Dutch academic research. Additionally, current evidence on young people’s approach to online sexual health content (von Rosen et al., 2017) is also scarce. Farrugia et al. (2021) conducted a qualitative analysis in Australia that focused on online sexual information seeking amongst young people, and currently, no similar research has been conducted in the Netherlands. Nikkelen et al. (2020) suggested a gap in research regarding the influence of self-esteem and existing sexual knowledge on online sexual information processing. In addition, most existing publications have explored how much online information has been sought rather than the ways online information is approached (Nikkelen et al., 2021).

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In light of these gaps in knowledge, this research sought to explore and respond to the following research question: ‘How do young people in the Netherlands characterise their sexual health knowledge and online literacy?’.

Theoretical framework Sexual health

Sexual health is fundamental to people’s wellbeing. It is to be noted that sexual health is only a section of the larger spectrum of sexual and reproductive health and rights (SRHR).

In 2018, the Guttmacher-Lancet Commission proposed an integrated definition of SRHR.

Although this definition is extensive, there is a main concept that is especially relevant to this research. That is the human right of all individuals to have access over their lifetime to the information, resources, services, and support necessary to achieve healthy sexual relationships (with themselves and others), free from discrimination, coercion, exploitation and violence (Starrs et al., 2018). Moreover, the public health and human right standards are ‘availability, accessibility, acceptability, and quality’ (Starrs et al., 2018). Regarding the Dutch context, the sexual health education programme in the Netherlands is praised for its quality (Mevissen et al., 2017; Krebbecks, 2020). Yet, the sexual health statistics are still concerning. Mevissen et al. (2017) described that 7.4% of girls between 15 and 19 years old have experience unwanted pregnancy, 60% of chlamydia infections happen among youth below 25 years old, 40% of girls between 15 and 17 years old are subject to sexual-related behaviours against their will, and finally, one in twenty young adults reported they were incapable of being friends with a homosexual person.

Moreover, sexuality education in schools in the Netherlands faces a couple of

challenges. Firstly, sexuality education is only offered from age 13-15 as some students quit biology classes in senior years – 16 years old and above (Cense et al., 2020). This could be a

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reason why it is less effective as some students may lack the maturity to process this type of information, and most of them are not sexually active yet. The second issue with classroom sexuality education is the lack of a safe class atmosphere to address sexuality. Addressing this topic in class can sometimes lead to public ‘outing’ of sexually active students, bullying in general (Cense et al., 2020; Pound et al., 2016). This is especially difficult for LGBTIA+

students and students of colour as not only the curriculum is not tailored to fit their needs (Cense et al., 2020), but they can feel unrepresented, unsupported, bullied and stigmatised during sexuality education classes (Roberts et al., 2020). This lack of representation and support leads to students turning to extra-curricular resources to seek sexual health information, often online resources (Roberts et al., 2020).

For this reason, this research aims to explore how to further improve the sexual health education systems, especially outside of the school curricula and online. As this area of research is still growing, previous research is often qualitative (Farrugia et al., 2021; Pounds et al., 2016; Roberts et al., 2020; Cense et al., 2020; de Gee et al., 2020; Dalenberg et al., 2016). Concepts that were addressed in the interviews are the participants’ perception of the sexuality education they received in school (Roberts et al., 2020; Pound et al., 2016), their current state of sexual health knowledge (Cense et al., 2020), and the source of their knowledge (Roberts et al., 2020, Farrugia et al., 2021; Pound et al., 2016).

Health literacy

Health literacy is the degree to which one can obtain, process, understand, and communicate about health-related information needed to make informed health decisions (Meppelink et al., 2015; Sørensen et al., 2012; Vamos et al., 2018; Vongxay et al., 2019).

Approximately 25% of the Dutch population has inadequate health literacy (Meppelink et al., 2017). Moreover, in 2013, a survey evaluating health literacy in the Netherlands revealed that

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accessing information on healthcare was perceived as more challenging than accessing

information on disease prevention (Mevissen et al., 2017). These scholars found a relationship between socio-economic status (SES) and health literacy levels, lower SES resulted in lower health literacy. Nevertheless, the authors highlighted that no matter the SES and literacy levels, different individuals have different difficulties depending on the topic they are seeking information about. Some might have an easier time with understanding the information but struggle with applying it, while others have an easy time accessing the information but difficulties understanding it (Mevissen et al., 2017). This highlights the importance of developing sexual health information to make it accessible and approachable to every individual in a non-discriminatory manner. For this reason, it would be insightful to assess whether youth in the Netherlands also have personal preferences and approaches to online health information (Mevissen et al., 2017).

Similarly, sexual health literacy provides the ability to understand sexual health information and application of that information (Rakhshaee et al., 2020). This enables individuals to make informed decisions, increase preventive behaviour and overall reduce health risks (Vamos et al., 2018). In case of low sexual health literacy, poor sexual health decisions are likely to occur (e.g., delays or difficulties in seeking care) (Vamos et al., 2018).

In the case of the sexual health literacy levels in the Netherlands, no English-language

academic reports were available. Most of the literature about the Netherlands addresses sexual health as a whole, with a focus on the LLL+ intervention (Mevissen et al., 2017), and often with emphasis on youth from a migratory background (de Gee et al., 2021; McMichael &

Gifford, 2009). For this reason, this research explored perceived sexual health literacy levels amongst participants based in the Netherlands.

Finally, online health literacy was a key component of this study as it explored online content. Seeking online health information (OHI) is a common tendency. Many use it for

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health purposes such as self-diagnosis or avoiding a visit with their General Practitioner (GP) (Diviani et al., 2019). OHI is popular due to its ease of use and availability. However, it can be challenging to understand the information encountered online and evaluate its credibility (Diviani et al., 2019). Moreover, OHI is not centrally controlled, basically anyone can spread information (Meppelink et al., 2019). For this reason, higher levels of online health literacy equip individuals with better criteria to assess the quality of OHI, and ultimately make better- informed health decisions (Meppelink et al., 2019). In terms of sexual health, research finds a key type of sexual health content sought by youth is information and reassurance about norms of sexual behaviour (Martins, 2017). This study further explored if this is also a key search topic for youth in the Netherlands.

Assessing the understanding of online sexual health content was an important component of this study. Nonetheless, the quality of the online content as well as trust in different sources was explored too. According to Farrugia et al. (2021), students tend to prefer official or science-based websites with citations at the end and, for instance, .org, .gov

websites. Students also trust these scientific sources more (Farrugia et al., 2021). In addition, exposing youth to credible sources of information could have the potential to reduce health literacy challenges and reduce trust issues with various sources (Ghaddar et al., 2012).

However, even on official websites, Farrugia et al. 's (2021) participants have a tendency to approach the information critically. Some participants even reported being more sceptical of official or authoritative sources than resources informed by personal experiences.

In light of a growing use of Internet to seek health information (Diviani et al., 2019) and insufficient levels of health literacy in the Netherlands to appraise the uncontrolled online content (Meppelink et al., 2017), as well as a lack of trust for online content, this current study addressed each of these themes. This is especially relevant in light of a lack of research on sexual health literacy specifically in the Netherlands.

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Epistemic citizenship

This leads us to the concept of epistemic citizenship which describes a pursuit of citizenship inclusion (sexual emancipation) through the enactment of specific values and practices such as fact-checking and evaluating difference sources of information (Fraser et al., 2021). This term was proposed by Fraser et al. (2021) and is an integration of the concept of

‘sexual citizenship’ with ‘episteme’. Sexual citizenship is the idea of claiming rights to live openly and without legal constraints. It encompasses the difficulties youth face to access reliable factual information and support of sexuality-related issues, and draws on the

importance to open up discourse about sexual practices and norms (Fraser et al., 2021). With this concept also comes ‘episteme’, it illustrates the way diverse intellectual fields share characteristics and create an ‘episteme’ common to all and acts as a basis, and boundary, for knowledge. In other words, individuals are not only sceptical of the content they are exposed to, but they feel a sense of responsibility to seek and find the ‘truth’. This research drew from this new concept and assessed whether there is indeed a sense of epistemic citizenship in youth in the Netherlands when it comes to finding information on sexual health.

Moreover, when choosing a preferred source of information, there is a distinction between factual information (physical health, sexually transmitted infections, etc.) and subjective information such as relationships, consent, etc. (Farrugia et al., 2021). Farrugia et al. (2021) found that youth prefer website presenting experiences rather than just facts. Similarly, Nikkelen et al. (2020) explored the differences in source preferences and they uncovered differences in preferences towards professional content or user-generate content (UGC) based on gender, sexual experience and problems, and self-esteem. These findings provide

directions to guide this research as the type of information (factual vs. subjective) and external factors such as gender and sexual experience could influence the occurrence of fact-checking and source scepticism, whether such mechanisms do take place or not.

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In light of this tendency to mistrust online health information, the current study explored whether there is a sense of epistemic citizenship (Fraser et al., 2021) in youth in the

Netherlands, and whether they have source preferences and which factors influence these (such as content sought, gender, needs) (Farrugia et al., 2021; Nikkelen et al., 2020).

Method Research design

This research took the grounded theory approach, which means the researcher should allow the world to present itself without applying their individual perspective (Glaser &

Strauss, 1968). In light of the research question ‘How do young people in the Netherlands characterise their sexual health knowledge and online literacy?’, the most suitable method was qualitative research as it allows for deeper understanding of participants’ perceptions and needs. The qualitative method has the advantage to be flexible and data-driven, which allows the discovery of unexpected findings instead of testing pre-defined hypotheses (Hammersley, 2013). The data was collected through in-depth semi-structured interviews. This is an

effective method to gain insights from participants as in a semi-structured interview participants select the details and experiences that come to their mind rather than strictly choosing between pre-selected responses in a survey (Mears, 2015).

Participants and recruitment

Data collection took place in the last two weeks of May 2022 and consisted of nine semi-structured in-depth interviews. The sampling method for this research was purposive sampling, the participants were selected deliberately to ensure different age groups, genders, and sexual orientation, which provided rich data in light of a short time-frame and limited resources. The criteria for recruitment were that participants should have been in the Dutch

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educational system during the high school years in which sexuality education is taught (11-16 years old). The target sample was between 18 and 25 years old and was based in the

Netherlands. Participants voluntarily offered their participation after being exposed to a general invitation message on Instagram. The voluntary character of participation was

especially important due to the sensitive nature of this research, as discussing sexuality might be uncomfortable for some. One participant was recruited through snowballing after an acquaintance participated in the interview and asked them if they wanted to participate.

Theoretical saturation occurred after nine interviews, four identified as male and five identified as female, the age ranged from 19 to 24 years old and the mean sample age was 22 years old. Overall, all participants had a medium to high level of education. All the

participants were atheist, one identified as agnostic, and one specified they went to catholic school but did not consider herself religious. In terms of sexual orientation, six participants identified with the LGBTQIA+ community, and three identified as heterosexual (see Table 1).

Table: Overview of participant characteristics Age Gender

identity

Highest level of education

Religious beliefs Sexual orientation

Years sexually

active Participant 1 24 Male MBO4 Atheist Heterosexual 6/7 years Participant 2 23 Female Master Atheist Heterosexual 5 years Participant 3 20 Male MBO4 Atheist/Agnostic Bi-curious 3 years Participant 4 23 Female Bachelor Atheist Bi-curious 8 years Participant 5 22 Female Master Atheist Bisexual 1 year Participant 6 24 Male Bachelor Atheist Heterosexual 8 years

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Participant 7 19 Female MBO4 Atheist Asexual/pan- romantic

Asexual

Participant 8 24 Male Bachelor Atheist Bi-curious 8 years Participant 9 22 Female Master Atheist Bisexual 7 years

Interview procedure

The interviews were conducted individually online through the telecommunications platform Zoom. The interview language was English, to facilitate communication and ensure complete data, participants were allowed to use Dutch words in case they were struggling with English terms.

In the week prior to the interviews, the interview guide (Appendix A) was tested with peer researchers to ensure quality and smoothness of the interviews, and correct any mistakes or confusing questions. The interview guide was corrected accordingly. Before the interviews began, participants were asked to sign an informed consent form (Appendix B) explaining the nature of the research, the process, the privacy of the data and their right to withdraw from the study at any given moment.

The interviews were recorded with the Zoom recording tool and a backup was

recorded on an iPhone from which the recordings were deleted once they were transferred to a secure hard drive. At the beginning of the recording, participants were asked for their vocal consent to record the interview and follow-up with the interview. The interviews lasted between 22 minutes and 70 minutes; the average of interview length was 33 minutes. Out of the nine interviews, all started with videos turned on, but due to Internet connection issues three participants had to keep their camera switched off, which removed some non-verbal communication.

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Sensitivity of topic

As sexuality is a sensitive topic, the interviews were semi-structured, which enabled the participants to guide the data collection and overall elicited rich descriptions. In other words, the grounded theory approach encouraged the participants to drive the conversation and feel they had control over discussing this sensitive topic and choosing the information they wished to disclose. This method is inductive and the theory emerges from the data.

(Khan, 2014). Nevertheless, the semi-structured format did allow for the researcher to prompt the conversations into the desired direction (Khan, 2014).

Researcher reflexivity

The researcher is the research instrument. As for every research instrument, biases must be addressed (Dogson, 2019). For this research especially as sexuality is a sensitive topic, the researcher needs to be clear as to their position towards the topic. In terms of socio- economic status, the researcher is a white, upper-middle class, cisgender, straight, non- disabled female. The researcher is non-religious and highly educated. The research is

conducted in the context of a Master thesis, which might have influenced responses in either of two ways: either the participants were more inclined to respond as the research was unlikely to be published so their responses were not going to be diffused, or the participants were less genuine in their responses as they might have considered the scientific outcome of this research as having a low importance. Moreover, part of the interviews addressed the Dutch education system and sexual education in secondary school in the Netherlands, but the researcher is from Belgium and has followed secondary education in a specialised school, meaning the curricula differed. For this reason, the researcher was not able to relate to some of the anecdotes the participants referred to. Moreover, the participants were all native or proficient Dutch speakers, but the researcher was a beginner with the Dutch language, and as

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the interviews were conducted in English, some information may have been lost in translation or participants may have refrained from addressing certain issues due to a language barrier.

Regarding ethnicity and sexuality, the researcher is not part of a sexual or ethnic minority, however, participants from minority groups were recruited and encouraged to discuss their point of view on the issue as one of the goals of the research is to make sexual health

information accessible and relatable to all. As the researcher is not from a minority group they may not have felt as safe to disclose their point of view. Finally, the researcher is from the same generation as the participants and experienced their own lack of sexual education first- hand while often resorting to external sources to seek sexual health information. Therefore, the researcher was personally in touch with the topic and may have related to participants more easily due to their own experiences.

Interview outline

The interview guide for the semi-structured interviews addressed the main research question and the three sub-topics: sexual health knowledge, online sexual health literacy, and source trust. The interviews started with a presentation of the topic and context of this research, followed by verbal consent to participate and to have the interview recorded.

The first topic of the interviews assessed the perceived level of sexual health education the participants received. In this section, the participants were shown a list of sexual health topics retrieved from Hawkes’ (2014) list of concepts and the WHO definition (World Health Organisation, n.d.). They were asked to non-judgementally assess their knowledge of each topic. To avoid the participants feeling as though they were being tested, they were given three smiley faces and asked to use them to rate each topic. The topics were: Contraception, (in)fertility, prevention and care of STIs/HIV, gender-based violence (e.g. sexual violence), abortion, stigma and discrimination on the bases of sexual orientation, stigma and

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discrimination on the base of gender, sexual dysfunction, mental health issues related to sexual health, endometriosis, consent, pleasure, the female reproductive system, and the male reproductive system. The goal of exposing participants to this list of concepts was to trigger their existing knowledge of sexual health and reflect on it, with the aim to facilitate

conversation on their sources of information (van Braak et al., 2018).

This led the conversation towards the sources of information for their knowledge of these topics and towards the next topic of online sexual health literacy. This section discussed sources of choice and the participants were shown two short texts about HPV. One was derived from an official medical website (Centers for Disease Control and Prevention, 2022), and the other one from user-generated content (Head, 2021) (see appendix C). The

participants were asked about their understanding and preferences towards the texts respectively. The goal of exposing participants to these two texts was to ensure that every participant had a similar understanding or reference when the researcher referred to ‘medical versus blog-style’ sources (van Braak et al., 2018).

Finally, the last topic of source trust was addressed and touched upon the concept of epistemic citizenship, this section discusses sources in terms of the number of sources they use, their preferred one and whether they feel satisfied with the information available. Lastly, the last part of the interviews included questions about demographics and external factors such as their own experience with online sexual health information searching, and wrap-up comments. The participants were thanked for their participation and encouraged to ask any question they might have.

Data analysis

The data was transcribed with an online automated transcription tool, Otter.ai. Every transcription was thoroughly checked and corrected, which allowed initial note-taking and preliminary analysis to take place. As the data was being analysed simultaneously to the data

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collection, theoretical saturation was reached after nine interviews as patterns had appeared and interviews began to be repetitive. The transcribed texts were subsequently coded with the qualitative analysis tool Atlas.ti. In the open-coding phase, 337 codes were created. Following this, the focused coding process and grouping of codes took place – 266 codes were left, and 19 code groups were extracted.

Results

Following the coding process, four themes came out from the participants’ answers and emerged as insightful. These are: problems with school sexual health education, participants’ searching patterns and habits, epistemic citizenship, and the description of characteristics that would constitute an ideal online source of sexual health information (see the concept-indicator model in Appendix D).

Problems with school sexual health education in the Netherlands

The first issue that emerged from the data and was recalled by several participants was heteronormativity - the Western social norm, or assumption, that the overwhelming majority of sexual relationships in society are heterosexual (Jeppesen, 2016). It might be relevant to note that four of those participants identified with the LGBTQIA+ community. Participants mostly described sole focus on heterosexual intercourse, and no mention of other sexualities in terms of intercourse as well as awareness of the possibilities.

“This is heterosexual reproduction. And sex in relation to its reproductive purpose.

[…] A lot of the sexual health education you actually really need for queer people is just missing. I've never had any sort of education on queer sexuality, you know, sex for queer people. Which, you know, we've seen in studies kind of, this effect where queer people might not know that they need to, you know, wear a condom or any sort

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of protection during sex, you know. And they too have STDs, you know, like, that isn't exclusive to heterosexual sex. And, I don't know, I think they just scratched the

surface of what the conversation should be.” (Participant 3, 20, M)

With regard to this heteronormativity, several participants associated it with the time at which they received their sexual health education in school, which ranges from ten to three years ago. Participants who received their sexual health education around nine to ten years ago considered that “these are kind of newer concepts” (Participant 8, 24, M) and “[teachers]

weren’t that forward in that way” (Participant 2, 23, F). Nevertheless, Participant 7 (19, F) was the youngest of the sample and described that they were taught that “gay people

experience it another way than a hetero person does” but that the topic was not addressed in detail and they felt her teacher didn’t know anything about it.

Another issue raised by several participants was the extent to which their sexual health education was biology-focused and “too basic” – that is, not enough themes were covered, and the ones that were covered were often not covered in-depth. For a couple of participants, sexual health education was a chapter in a book which they had to study for a test. The majority felt they learned about the male and female anatomy, the biological mechanisms of reproduction, safe sex, and contraception rather than learning about more practical knowledge or the emotional dimension of sexuality. Nearly every participant described that they learned how to place a condom on an object, and this was as far as practical knowledge went.

Participant 4 (23, F) described it as “I thought she could have actually told us things that we now know at our age, but only because of experience”. Similarly, some felt that the content of the course did not “tap into what interests young people about sex” (Participant 3, 20, M).

Moreover, seven out of the nine participants felt that the classroom was not a safe space to open up about sexuality. There were two main reported causes for this lack of comfort. The first one was the teacher. Some participants did not feel comfortable with their

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teacher, disliked them, or simply felt that the teacher was not the right fit to teach such a subject. Participant 5 (22, F) considers that their dislike for the teacher is the reason they did not enjoy her sexual health education class. The second and main reason associated with the lack of a safe space in the classroom was the setting itself. Participants described the

experience as awkward and nearly all experienced laughs and giggles during the class.

“I think the age at which we got the information was way too late. And so it became just taboo and everyone was laughing and made fun of it, which is, I suppose, an obvious reaction from kids that age. […] Because it was in such a classroom setting, it made it very difficult, I think, for people who might have had or might have been active or might have had questions, in regards to things that they experienced or whatever. They don't really feel like opening up in a classroom setting with 30 kids who are all making fun of the subject to begin with.” (Participant 1, 24, M)

Participant 1 (24, M) felt that offering sexual health education at a younger age would reduce the taboo associated with the topic and leave a safer space for children to ask

questions. In fact, Participant 8 (24, M) recalled one girl in his class attempting to share a personal story on the topic of genital wards and she was mocked by the rest of the class. By highlighting the lack of a safe space in the classroom, this last point leads us into the next theme of the results, which is learning that takes place outside of the classroom – the online searching patterns and habits.

Searching habits and patterns

In this section, participants were asked about their main sources of information, their online searching habits and satisfaction with regard to sexual health. Participants were first asked to reflect on where they gained the most of their knowledge on sexual health. The majority cited the Internet as their main source of information, and two of them considered

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their friends were their main source of knowledge. Other sources of knowledge participants mentioned were personal experience, television programs and documentaries, podcasts, word- of-mouth, children’s magazines, and family. Three participants mentioned school and

specified they only learned the basics and biological knowledge there.

“Well, in school, I just learned the pure biological aspect and the prevention of STIs.

And like the bare basic minimum. But most, most of it especially when it comes to non-heterosexual non-cisgender topics, I just learned combination of word of mouth, talking to people and the Internet, just being exposed to topics watching videos on YouTube, or is looking stuff up myself about it. […] Definitely the Internet has the most resources, just, you know, there's, there are so many people who are likewise interested and passionate about spreading that knowledge. You know, that, that has become a huge resource.” (Participant 3, 20, M)

Moreover, participants were asked to rate their estimated level of knowledge on various sexual health topics. The results show an insightful distribution of knowledge. The topics that participants felt they had strong knowledge about were: 1) stigma and

discrimination of the basis of sexual orientation, 2) stigma and discrimination on the basis of gender, 3) consent, 4) contraception, and 5) mental health issues related to sexual health. On the lower score sides, the topics participants felt they had a medium level of knowledge about were 1) sexual dysfunction, 2) fertility, 3) both male and female reproductive systems, and 4) prevention and care of STIs. Endometriosis was the topic participants perceived they had the least knowledge about. In this distribution of scores, it appears that participants felt the most comfortable with knowledge they were not taught in school (non-biological topics), and were most hesitant with purely biological topics which are the ones they were taught in school.

Contraception was the only exception. As most participants mentioned that they refer to the

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Internet as their main source of information, the interviews further explored participants’

online search habits.

Firstly, every participant except one reported that they had searched about sexual health topics online in the past. Several participants report simply googling a topic and clicking on the first results available, and a majority of participants preferred reading medical websites.

“If I Google, so I probably Google it. And then I'd try to see if there was like a more uhm official website, maybe like a doctor's website or like, a hospital's website or something, something a bit more official with like an actual doctor or health experts talking about it.” (Participant 6, 24, M)

In general, every participant except one felt that they always found the answer they were looking for. However, Participant 9 (22, F) considered that they are not always satisfied with the online results and that those can be too black-and-white.

“I do feel like it's not always as like practical knowledge, if that makes sense. For example, with like gay sex between girls you have like this thingy that you can use kind of like a condom. And I don't know anyone who uses that. And then if you're hooking up with multiple people, it's smart to look into you know, what you can do to be safe anyways. And then all those websites will just tell you to use that period. And I feel like sometimes it's like, not that black and white. Also, with sex with guys where I feel like there's a lot more information online, […]. Feel like sometimes it's a little bit too black and white, if that makes sense.” (Participant 9, 22, F)

Source trust and preference

The first main finding in this section was that every participant systematically checks multiple sources when they research (sexual) health information online. Several used the

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expression “to double-check”, overall, participants described doing so to “make sure they’ve got the right information” (Participant 2, 23, F) and “to see if it says the same thing”

(Participant 4, 23, F). This finding brings us into the topic of source trust and preferences.

Participants described that the Internet is not always trustful due to the amount of information available online, and the freedom for anyone to publish content.

“Um, just because the Internet is full of [lies] in general. Um, I find that like in practice when you Google something, the first few hits are usually fine, especially if it's common questions. Um, but I've also seen the, the more ridiculous sides of the Internet where people make absurd claims about stuff. So, it made me sort of aware of like, wait, double-check something. And if two or three different websites that all claim to be medical say more or less the same thing. Then it's probably, uh, more reliable information. Um, but if like, you know, the first one says, oh, if you have genital wards, you should put coconut butter on it. And then none of the others

mentioned that I'd be like, let's not <laughs>, let's not try that.” (Participant 8, 24, M).

Furthermore, most participants agreed when they were asked if they would consider that they are searching the truth – which corresponds to the sense of responsibility to find the

‘truth’ described by Fraser et al., (2021) in their definition of epistemic citizenship.

Participant 2 (23, F) considers that even if an article gives very good information they always prefers to check “if what they’re saying is actually true”. This leads to the next point

participants reacted on, which is trust in different types of websites.

The main finding on source trust is that it truly turns on personal preferences. From the two online articles on the topic of HPV that participants were asked to read, the majority of participants considered that both articles were equally trustworthy. However, some

participants did find the medical website slightly more trustworthy, but this was mostly due to the writing style rather than the author. Participant 5 (22, F) says “it feels more trustworthy

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because the second one is written, like, it has a small entertainment purpose […] instead of actually wanting to inform people” and participant 9 (22, F) says “it seemed like a medical course, like someone who is a researcher in the field […] And the second one felt like the writer just wrote like a summary of Google searched but she may make some mistakes”.

Participants did not report checking credentials of the authors but seemed to rely mostly on external factors such as layout and vocabulary. The main technique participants used to check source reliability was fact-checking, and making sure the same information was repeated on other websites.

The last criteria for online source choice explored in this section was the type of content participants sought. The opinions were scattered, once again this seems to be a personal preference. Some participants simply checked the first results that came up in the search. One participant did not use the Internet for emotional problems. For some, when they search about factual topics and health problems they mostly rely on medical and official sources, but for emotional topics they would rather read content written by psychologists or blogs.

“I'd say it's, I would probably look for a different source because like, well, health- related problems, I would prefer a more factual source but obviously, like relationship problems is very different. So I think I'm not really sure if there's like a source, like maybe more like a therapist or something like that.” (Participant 6, 24, M).

The perfect online source for sexual health information

Participants were asked to describe the ideal source of sexual health information online, in light of this, the most recurrent answers provide insights for an ideal source of information for this age group. The first point often brought up was the the source should be visually easy to navigate. Participants mentionned a smart bar (i.e. adapts to typos), a

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summary at the beginning of articles regrouping the main points covered, and many mentionned bullet points. In addition, some participants mentioned the importance of the general visual appeal of websites.

“I think, uh, the author doesn't really matter that much to me, as long as it's, uh, clear, uh, the structure of it. That should be clear to me. Um, so you shouldn't have to dig through the [article]. It should really be clear upfront where you can find the

information and maybe, um, also depending on the topic, but some bullet points are always good for me cuz they're like a visual, uh, thing. So it's not like one big bunch of texts, but bullet points really break up the text and it makes it easier to read in my opinion.” (Participant 2, 23, F)

Moreover, four mentionned that the content should be presented in a digestible form.

The information should not only be easy to navigate, but should also be presented in a digestible size. In addition, some prefer if the information is “phrased in a way that makes sense instead of calling everything by their scientific name” (Participant 8, 24, M). In

addition, one participant proposed the option to consume the content either in text form or in video form depending on preferences.

“It's the digestible aspect of it because I do look at several sources, so I'm not looking forward to reading 30 page essays on several sites. That's why it's nice if it's 5 to 10 minutes read.” (Participant 1, 24, M)

With regard to authorship, although most participants did not perceive a strong author difference between the two articles that they read during the interviews, several described their perfect source to be written by a medical expert. Moreover, they often preferred the content to be on an official or expert website, “something that is supported to be very, very safe to read from” (Participant 4, 23, F).

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“I think the perfect online platform would be something which is definitely made by people who you know, are licensed within sexual, sexual health, sexual education, and all these all these topics. That they do have their the proper licenses when it comes to the writing of it. “ (Participant 3, 20, M)

Participant 9 (22, F) pictured a younger doctor writing the content and wishes to see more “practical tips” on how to handle certain common situations such as dealing with a partner who refuses to wear a condom. These responses altogether suggest that particiaipnts would want to see relatable content, easy to read, and from a safe and expert source.

Conclusion and discussion Summary and discussion of findings

The interviews conducted for this research outlined four themes: the problems with school sexual health education, participants’ online searching habits and patterns, a sense of

epistemic citizenship, and suggestions for an ideal online source of sexual health information.

With regard to the problems with school sexual health education in the Netherlands, the first issue that arose was the heteronormativity of the curriculum. Participants felt that the curriculum solely focused on heterosexual intercourse and in general did not discuss – or only scratched the surface –other sexual orientations. This finding confirms Cense et al.’s (2020) claim that the curriculum is not tailored to fit LGBTQIA+ students’ needs. Similarly, Roberts et al. (2020) found that LGBTQIA+ students could feel unrepresented, unsupported, bullied and stigmatised during sexuality education classes. While participants reported a lack of queer representation in the curriculum, none reported feeling stigmatised or bullied during sexual education classes. However, nearly every participant found that the classroom was not a safe atmosphere to discuss sexuality. They recalled that students were often giggly, the atmosphere awkward, no space for a conversation, and some teachers unfit to teach such a topic. Although

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it was predicted that this taboo in the classroom could be due to this class taking place at a young age – 13 to 15 years old according to Cense et al. (2020) – one participant suggested that the class was taught too late and would be less taboo if the topic of sexuality was destigmatised and taught at a younger age. Furthermore, and as predicted, every participant considered that the sexual health education curriculum was too biology-focused, teaching primarily body reproductive anatomy, STD risks and prevention, and contraception. An important finding was that, when assessing their own level of knowledge on a variety of sexual health topics, the results demonstrated that participants were more unsure about the biological knowledge they were taught in school than about emotional and practical knowledge that was not taught in school. Amongst others, these problems with the school sexual health education classes often led participants to turn to external resources, often online resource, which confirms previous research (Roberts et al., 2020; Nikkelen et al., 2020).

More specifically, nearly every participant referred to the Internet as their main source of sexual health information. As previous research finds, youth need to be equipped with good levels of health literacy to appraise online health information (Diviani et al., 2019). With regard to the participants’ (sexual) health literacy, they had an overall good understanding of both the texts they were presented – from a medical website and from a blog-style website.

The preference and ease to read for each text varied between participants and may not have been associated with the participants’ level of education as no pattern was present, which could confirm previous research by Mevissen et al. (2017). As some participants mentioned, the text-style choice seemed to be solely based on individual preferences. Overall, participants indicated a slight preference for medical or official websites, which is a finding that Farrugia et al. (2021) had highlighted in their own research on a similar sample. Another finding confirming Farrugia et al.’s (2021) claims is that participants turned to different sources

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depending the topic they sought. They consulted factual sources for physical health-related questions, and preferred psychology websites for more subjective or emotional questions (Farrugia et al., 2021).

In terms of the quality of online content, only one participant felt they did not always find the answers they were looking for and considered online information to sometimes be too black and white. Nevertheless, other participants were often satisfied with the results of their online research. Notably, to achieve these results, every single participant reported referring to multiple sources when they conducted an online search. They reported approaching

information critically and often feeling the need to double-check whether the information is truthful and reliable as they believed the Internet is also a place where misinformation can be spread as described by Meppelink et al., (2019). This finding confirms previous findings by Farrugia et al. (2021), and also confirms the concept of epistemic citizenship proposed by Fraser et al. (2021). Most participants agreed that they searched for ‘the truth’ as described by Fraser et al. (2021).

Finally, participants described their ideal source of sexual health information online.

Amongst the criteria they mentioned, the most recurring one was a visual ease to navigate through bullet points and summary, overall visual appeal, they also pointed out the content should be presented in a digestible form and be written by experts or professionals in the field, but ideally the content should be written in an accessible vocabulary. This last finding leads us to the next step of this conclusion, which is the implications of this research.

Theoretical and practical implications

The first practical implication of this research provides suggestions to improve the sexual health education curriculum in the Netherlands. Although the Long Live Love+

programme aimed to improve the quality of sexual education and reduce prejudice towards

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sexual minorities (Mevissen et al., 2017), the findings of this research show that this

intervention did not suffice to provide a diversified curriculum, nor to teach sexualities other than heterosexuality. Participants’ criticism of their sexual health education class confirms Cense et al.’s (2020) observation that the Long Live Love+ intervention was not sufficient to make school sexual health education inclusive. Overall, participants suggested a more

inclusive curriculum, more focus on non-biological aspects of sexuality such as practical and emotional information. In addition, more effort needs to be invested in the provision of a safe space in the classroom, open for discussion and without any taboos. One of the suggestions was to teach sexuality education at a younger age to destigmatise the topic.

Furthermore, the other practical implication of this research encompasses the

suggestions participants provided for an ideal online source of sexual health information. As mentioned in the findings, they suggested the ideal website should be safe to read from and written by experts, ideally someone young. The information on the website should be

medically reliable, but presented in an accessible language. Moreover, the information should be presented in a visually-appealing manner and be easy to navigate, presenting summaries and bullet points. The number of topics covered should be broad, presenting a variety of solutions and points of view, including some experiential accounts. The topics should be medical, but should also include practical knowledge and tips such as communicating with a partner. As one participant suggested, and considering several participants reported referring to YouTube to search for online sexual health information, an audio-visual version of the information should be available.

Finally, this study contributes to scarce research on this topic as most research focused on the frequency of online searching rather than the content and types of websites sought. It begins to fill this gap in literature and its findings open the way for future research to further fill this gap on content sought online for youth in the Netherlands.

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Limitations and future research

The first and main limitation of this research lies within certain aspects of the interviewing procedure. Firstly, as the participants were recruited through the researcher’s personal network, some of the participants knew the researcher personally prior to the

research. This could have affected the results in either of two ways, either the participants felt more comfortable with the researcher and more willing to open up as they trusted the

researcher, or it could be that social desirability played a role as participants may not have wanted to share information which they could have considered as too personal to share with acquaintances. Vice versa, for the participants who were not previously familiar with the researcher, they either opened up less as they did not have an established relationship of trust with the researcher, or instead, they might have felt more anonymous and therefore more willing to share personal information. Notably, no participant mentioned pornography as a source of information (Krahé et al., 2021), which could be either because it was the case that they did not consider it a source of information, or due to the social desirability effect.

Moreover, another issue with the interview process was that it was conducted fully online, and three participants had to remove their camera due to Internet connection difficulties. This online setting erased some non-verbal communication, and might have created a less

comfortable atmosphere for some. All of these factors combined might have hindered the validity of this research. Future research should be conducted face-to-face, with participants that do not know the researcher personally prior to the research to reduce some social

desirability aspects. However, participants should ideally meet the researcher once prior to the interview to ensure increased comfort during the interview itself.

Another limitation can be derived from the sample. Due to the limited time and resources available to conduct this research, the interview topics were short and theoretical saturation was reached after nine interviews. In addition, most of the sample was highly

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educated which could explain the high literacy levels of the sample and overall ease and preference for medical content. In addition, due to the rapidly changing social norms on sexuality, it would be insightful to interview younger participants that have received their sexual health education more recently. Finally, the sample comprised a majority of persons identifying with the LGBTQIA+ community, but no participant belonged to an ethnic minority as they were all white and Dutch, and one Belgian. Overall, the size and profile of the sample reduces external reliability of this research and cannot be generalised to the broader population of youth in the Netherlands.

Similarly, these findings open the way for further research which could quantitatively explore participants’ claims. Moreover, no patterns could be revelaed due to the qualitative nature and small sample size of this research. For instance, no pattern of online searching depending on gender or sexual experience (Nikkelen et al., 2020) could be highlighted. Future research could seek to quantitatively explore whether such a pattern exists in addition to confirming whether the participants’ claims and opinions are generalisable.

Lastly, although participants all had personal preferences for different styles of text (medical or blog-style), education was not a cause (Mevissen et al., 2017). Further research could seek to identify whether other factors play a role in text-style preference.

Conclusion

This study finds that youth in the Netherlands is not satisfied with the sexual health education they received in school and often rely on the Internet as a main source of

information. This research highlights the importance of providing safe and reliable

information online, and to tailor both school sexual health education and online information to the content that youth are interested in seeing. The Internet is a promising tool for education, listening to youth’s wants and needs could be the key to achieve its best potential.

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Appendix A: Interview guide

Introduction:

• Research on sexual health education in the Netherlands.

• This interview in the context of my Master thesis with the University of Amsterdam, your data is collected entirely anonymously and you will be unidentifiable in the reports.

• Sign informed consent form

• Ask for consent to record the conversation, followed by repeated consent at the beginning of recording.

• Procedure explanation, open conversation with no wrong answers. Non-judgemental

• Do you have any further question or comment before starting?

General information

Goal: Gather demographic and background information to help making sense of the data

• How old are you?

• What is the highest level of education you have achieved?

• Which religion do you subscribe to (if any)?

• Which gender do you identify as?

The next three questions are about your own sexuality, it helps me putting your answers in a context, but you are not obliged to disclose certain information if you are not comfortable.

• What is your sexual orientation?

Figure

Updating...

References

Related subjects :