Friends as Informal Educators: The Role of Peer Relationships in Promotion of Sexual Health Services among College Students

Abstract

This ethnographic study of one United States university’s sexual health resources explores the role of peer relationships in sexual health promotion to understand how these relationships shaped students’ interactions with campus sexual health resources. Through analysis of seventeen semi-structured interviews with students, five policy interviews with providers and university personnel, and participant-observation of peer health educator training, the authors examine how trust in peer relationships can serve as a form of social capital to influence sexual health information sharing. The article introduces the term “peer administrator” to describe student actors who sit at the intersection of friend and official resource and explores the importance of these mentoring relationships for sexual health promotion. The analysis also considers how more individualistic models of public health promotion limit the impact of peer relationships and concludes with a discussion of how universities might imagine new forms of sexual health promotion among students.

On college campuses, students are often navigating health care seeking on their own for the first time, a task made especially tricky for stigmatized sexual and reproductive care, such as testing for sexually transmitted infections (STI), access to contraceptives, and abortion.^1–3 Understanding the role of peer relationships for university students learning to navigate these services can provide insight into sexual health promotion at a community level and ways to improve students’ overall wellbeing. Even when college campuses provide free or low-cost access to this care, additional barriers exist. Among college students, knowledge of the availability of sexual and reproductive health services is associated with receipt of such care,⁴ perceived reputation, cost, confidentiality, and convenience of the health care setting shapes decisions to seek STI testing,⁵ and university programs and resources impact comfort with discussions of sexuality.⁶ Structural limitations and social context play an even larger role in shaping young people’s options for sexual health care. Restrictive laws requiring parental consent or limiting access to certain services, health care costs, and a deficiency of youth-friendly services make seeking reproductive and sexual health services particularly difficult for adolescents and young adults.³

Given high rates of sexual violence on college campuses and increased calls for action, more universities are engaging in critical conversations about comprehensive approaches to student sexual wellbeing.^7,8 In this context, understanding how college students navigate their sexual health care options becomes crucial for universities re-imagining their approach to initiatives around sexual wellbeing. For this article, we apply the World Health Organization’s definition of sexual health as 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.”⁹

Individualistic models of sexual health that overemphasize personal responsibility and individual behavior change rarely capture the nuanced role of social and structural context, and importantly, relationships with other students, in shaping sexual wellbeing. These models create cultures of blame and stigma¹⁰ and ignore structural barriers that impact sexual health.¹¹ Through an ethnographic case study of one United States university, this article explores the role of the “friend educator” that Byron described in students’ understanding of their sexual health care options.¹² We argue that the trust underlying friendships that students use to learn about campus resources is a form of social capital, one that enables some students to experience fewer constraints in accessing sexual health care.

While a portion of the labor around sexual health education happens through unofficial relationships like friendships, we will also analyze the role of students in more official campus initiatives. These student employees are what we call, “peer administrators;” student mentors that sit at the junction between friend and authority. We define peer administrators as undergraduate students employed by the university that receive compensation and training to mentor other students. They have formal obligations, such as being mandatory reporters for issues of sexual misconduct and expectations for the number of hours that they must spend advising other students. At the same time, peer administrators are close in age to their advisees, share a social environment with younger students, and have recent experiences with learning about resources and transitioning to college themselves. The student health center does not have its own group of peer administrators, but given the mentoring work of all peer administrators, they still often serve as an important health resource. We explore how factors like training and depth of mentoring relationships influence the role of peer administrators in sexual health care information dissemination.

Social Relationships and Perceptions of Sexual Health Risk

We must consider the framing of risk in sexual health resources for young people when seeking to understand students’ perspectives on those resources, especially when those interpretations happen in conversations with other young people. Shoveller and Johnson and Helmy argue that dominant constructions of young people’s sexuality reinforce assumptions of risk.^13,14 Shoveller and Johnson explore how peer health education programs can reinforce discourse around young people as a risky group and create a dichotomy between safe and knowledgeable and ignorant and risky. They describe how, rather than empowering youth, these initiatives turn young people into agents to reinforce judgement as peers.¹³ Helmy similarly challenges constructions of young patients as ‘high risk’ in her ethnographic study of providers’, patients’, and reproductive health leaders’ perspectives on the promotion of long-acting reversible contraceptives in New York City clinics. According to Helmy, rather than acting impulsively as some providers presumed, young people made complicated and nuanced calculations of risk based on relationship dynamics, communication with parents, and personal comfort with the contraceptive method.¹⁴ Both pieces point to the importance of understanding young people’s sexual health risk in the context of broader social relationships.

Hopfer and Clippard also emphasize the role of social relationships, like family and peer messaging, in shaping both acceptance and resistance to HPV vaccines among college women. In their study, while provider messaging did play a significant role in decision-making around the vaccine, communication outside of the clinic setting altered women’s perceptions of both their risk for HPV and their ability to overcome institutional barriers to access the vaccine.¹⁵ This study will build on this research with a focus on how peer communication interacts with institutional barriers for other sexual health services on a college campus, highlighting how and when social connection transforms perception of social and biological risk.

Friendship and Social Capital in Sexual Health Promotion

Bourdieu’s conceptualization of social capital, or the actual or potential resources connected to group membership, aptly applies to the role of peer relationships in sexual health promotion.¹⁶ Examples of social capital include access to privileged spaces, improved understanding or expertise, and emotional support all obtained through friends or other social connections. Chase argues that social capital can help some gain access to crucial health resources.¹⁷ On college campuses, friends who know about sexual health resources and feel comfortable discussing them also exemplify a type of health-related social capital. Though social connections and the sometimes problematic sexual and contraceptive norms (e.g., misinformation or peer pressure) that come with them can increase college students’ risk for STIs,¹⁸ this study will demonstrate that these connections can also benefit students as social capital in the form of information and support that helps some students successfully navigate the bureaucracy of university healthcare.

Byron’s study of the role of friendship in young people’s sexual health negotiations demonstrates the positive impacts of these relationships. He notes that friends are different than the peer educators traditionally utilized in public health, distinguishing the intimate conversations of friendship as a unique space for sexual health discussions and highlighting the reciprocal and nonjudgmental nature of these relationships.¹² In Hernandez’s study of communication between sorority women about condom use, she similarly focuses on the importance of frequent interpersonal exposure for building the closeness and trust necessary to facilitate discussions of sexual risk-taking.¹⁹ Both Hernandez and Byron highlight the benefits of open communication about sexual experiences and risk taking with friends, something that this study will argue is a form of social capital useful in navigating sexual health resources.^12,19

Sexual Citizenship

Finally, Hirsch and Khan’s book Sexual Citizens: A Landmark Study of Sex, Power, and Assault on Campus also adds background to our findings through its discussion of the larger community project of sexual citizenship in university settings.²⁰ The book applies an ethnographic lens with a mix of qualitative individual and group interviews, surveys, and participation observation to explore sexual assault at Columbia University. In it, Hirsch and Khan define the concept of sexual citizenship as a “socially produced sense of enfranchisement and right to sexual agency” and argue that the state, educational systems, and families have failed to support the development of young people’s sexual citizenship.²⁰ While their study centers on sexual assault, these insights into sexual citizenship also apply to other sexual health concerns and help explain different levels of students’ comfort accessing sexual health information in peer relationships.

We examine the role of non-sexual peer relationships in college student sexual health promotion to understand how these relationships shape students’ sexual wellbeing. Specifically, we emphasize how peer relationships interact with official resources, what we define as university supported and sanctioned resources for health such as the health center’s website, formal workshops, printed materials, and conversations with providers. These findings may be of use to university officials and health care providers, campus health educators, and, most importantly, college students advocating for the sexual wellbeing of their peers or themselves.

Methodology

The data presented here come from a larger ethnographic study of how students at a private university in the Northeastern U.S. perceive and experience the campus sexual health services available to them. This mid-sized university has a fairly diverse student body and admits students of all genders from across the U.S., with approximately a fifth of the student body consisting of international students. While we derived the findings in this article primarily from interviews, we assert, like Hockey and Forsey, that ethnography is not only participant observation and emphasize the validity of interviews as a basis for an ethnographic work.²¹ We similarly define and employ ethnography by its purpose of creating “a written or filmic depiction of people,” and argue that the descriptive nature of this article’s findings qualifies it as ethnography.²²

Seventeen semi-structured interviews with undergraduates conducted between October and December 2019 ground the main findings of this study. These interviews ranged in length from 25minutes to an hour and focused on the students’ perceptions and past experiences accessing and using the emergency contraception, STI testing, regular contraception, and gynecological services, what we will call sexual health services in this article, offered at the student health center. The student health center provides a range of basic primary care services, as well as housing specialty practices (including an Obstetrics and Gynecology or OB/GYN department) and on-site pharmacy, lab, and diagnostic services. These services are only available to university affiliates (students and employees and their families), with some services exclusively for undergraduate students. In addition to the actual provision of care, the center encompasses a wellness office and some health education programming.

The first author, a trained anthropologist, asked students about their general understanding of these services, their process for learning more about what was offered, their experiences on the student health website, and their knowledge of pricing and insurance. When it came to experiences using the services, the interviews focused on why students chose the student health center, their experience scheduling the visit, their concerns before the appointment, and their interactions with their provider. Finally, the researcher asked students if they had ever decided not to seek one of these services at the student health center and for their recommendations (see Supplemental Materials for full interview guide).

To recruit students, the first author advertised the study with Facebook posts to the student class pages, physical flyers around campus, and messages to the email lists of various campus groups. Participants were provided with $10 as compensation for their time, which was intended to ensure that students would feel able to participate despite busy schedules without economic cost. Students did not need to have received services at the student health center to participate.

Participants ranged in age from 18–22, but tended to be older in grade year, with seven seniors, four juniors, four sophomores, and two first-years making up the seventeen interviews. Given the close community setting of the university, the first author did not systematically collect demographic information from each participant beyond what came up in response to interview questions. This was done to make participants more comfortable disclosing sensitive material. Participants self-reported any demographic information provided in the results below. Written informed consent was obtained, and all interviews were audio-recorded. All names in this article have been changed to pseudonyms to protect the identity of the respondents.

In addition to student interviews, the first author also conducted informational interviews with five health center providers and university personnel about the policies around provision and pricing of sexual health services (see Supplemental Materials). These informational interviews grounded a broader understanding of the university’s health services landscape and a sense of what educational efforts around these services currently looked like, as well as how university officials conceptualized these efforts and the barriers to care for students. The researcher obtained verbal consent to use these interviews as background information, but not to record or directly quote any of the providers or personnel. In lieu of audio recordings, the researcher took detailed fieldnotes during these interviews. Throughout the article, we will use the term provider to indicate a non-student employee of the student health center and personnel to indicate any non-student employee of the broader university.

Finally, in August of 2019, the first author observed the training session for student educators who teach sexual health workshops to all incoming first-years. These workshops discuss general sexual health education topics like sexuality, STI testing, sexual communication, and intimacy, as well as provide students with an overview of the university’s health services. In this training session, the researcher observed how leaders of the training presented information about student health policies to key educators and taught the educators to present these policies themselves. The first author also had access to the script for these workshops, which was analyzed alongside the fieldnotes from the session. Written permission to take notes on observations made during presentations to the entire group was obtained through email from the leaders of the training. In smaller breakout sessions within the larger training, the first author received further verbal consent from the participants of that session. The detailed fieldnotes from the training did not include any identifiable information.

For the final component of the research, the first author performed textual analysis of the student health center’s official website and pamphlets intended to inform students about the availability of sexual health services. These textual sources provided the researchers with a sense of the accessibility and content of educational resources available to students. For the website, the first author analyzed both its language, as well as its organization and the experience of navigating and moving through the site, engaging in a type of digital ethnography mediated through technology.²³

After collecting data, the first author transcribed the student interviews, then analyzed these transcripts alongside the textual sources and field notes from participant-observation and the informational interviews. The researcher applied the grounded theory approach, identifying analytical categories as they emerged in the data in a process of constant comparison.²⁴ The findings here represent a subset of the themes from the larger project that were most relevant to the topic of the article. Though transcripts included filler words, repeated phrases, and elisions from participants, the authors have removed some of these elements in quotes to make the meaning clearer to the reader. The data collection was approved by the Yale University Human Subjects Committee (HSC) Institutional Review Board, protocol # 2000025842. This board ensured that the study complied with all applicable laws, regulations, guidelines, and ethical principles.

Results

From our analysis, we identified four overarching themes concerning peer communication around sexual and reproductive health. These included 1) the role of informal peer communication about formal sources, 2) comfort with casual sexual health conversations, 3) the role of student-led sexual health education efforts and ‘peer administrators’, and 4) reflections on university-supported sexual health education workshops.

Students turned to friends as a source for logistical details about their care and experience-based knowledge to counter past negative encounters. The student participants recognized the role that they could play in their friends’ sexual wellbeing and wanted more information to help their friends. One student reflected on how past discomfort with the topic had prevented them from accessing their network of friends for experience-based reassurance, while another described the role that they played in helping a friend access services despite this discomfort. In more formal roles, students also helped their peers access information about sexual health resources, acting as what we call “peer administrators.” Peer administrators receive compensation and official training from the university, but identify as students. Some peer administrators also specifically mentor students with a shared identity, an official resource on sexual health that can be especially relevant for LGBTQ students. The length of these peer relationships distinguishes them from one-time sexual health workshops. While these workshops can set a valuable tone for the importance of sexual health on campus, they cannot fully respond to students’ evolving needs.

Informal Communication About Formal Sources

While providers and university personnel often described the official health center website as the most useful resource, when students explained how they learned about different services, they centered conversations with friends as their main source of information. Students experienced varying degrees of non-use of the website. One student said, “I didn’t actually even know that [the campus health center] had a website,” while others acknowledged its existence, but admitted that they did not use it as a main source of information. When discussing their understanding of the emergency contraception policy, one student, Skyler, said “my friend had used Plan B that she got for free from there, but otherwise I wouldn’t have known. I would have gone probably elsewhere.” While the health center website does list this service as free, students must have some initial awareness, as well as comfort with searching for that information, which often comes from peer networks.

Even for those who appreciated the website, a conversation with a friend preceded their search for information. When reflecting on her early experiences using campus health services, one student, Sasha, explained:

I remember I was talking with one of my suitemates about different kinds of birth controls, and they were like ‘Oh yeah, if you have the [university] specialty care coverage, they cover it all for you, it’s free’....It was definitely more like I talked to other people and then once I found out that it was free, I felt more motivated to go out and look for it myself, because cost was a deterrent for me.

While Sasha emphasized her later use of the website, it was a conversation with close friends that made her aware that this information might exist in the first place.

The first author’s experience using the website provided additional context for why some students might turn to a friend first. While the website included an emphasis on topics like no-cost emergency contraception and STI testing, this information did not exist in one central location. A page about birth control options, while rich in details about the mechanism and effectiveness of various contraceptive choices, did not include any information about insurance coverage or the process of seeking each option at the student health center. The information on STI testing and emergency contraception was listed under a different section than OB/GYN care and birth control appointments, and information about insurance constituted a completely separate page of the website. Hyperlinks helped to weave the pages together, but the first author found clicking through these various pages to be a somewhat dizzying experience of jumping from link to link, topic to topic with no centralized point of information.

The student participants had similar experiences navigating through this mosaic of information. One student, Stevie, described searching for information on STI testing:

Maybe it’s my Google search term, maybe I’m not putting in the right information to get where I want to go, but I find the website....a little circuitous, like some information is presented in 4 different places and some is either not there at all or is not highlighted in a way where it conveys its importance

While Stevie found the website still mostly useful, he experienced a segmentation of information that separated general sexual health information from logistical details of how to access that care. The experiential questions of seeking care could not begin to enter the picture.

The knowledge that the participants received from their friends expanded beyond simple logistical details like pricing or availability of services to the more experiential topics that the website could not answer, such as the tone of conversations with providers. In addition to their experience with emergency contraception, Skyler shared how conversations with friends had influenced their decision to seek STI testing. Past negative experiences with health care providers had initially made them anxious about the possibility of the student health center shaming them for their sexual health practices, like their choice to seek testing or their answers to intake questions about sexual behaviors. After accompanying a friend to get tested and hearing about his positive experience, they decided to make an appointment. They explained, “after seeing his experience, I felt a lot more comforted and encouraged that they would be supportive and also that more things would be covered after talking to lots of people about it.” Their decision also centered around some factual details like insurance coverage, but they emphasized the importance of a trusted account of non-judgmental care.

Reflecting comfort with sexual health discussions, some of the participants also recognized the role that they could play to help their friends and wanted information not just for themselves, but to share with others. For example, Robert, who expressed confidence in his knowledge of the sexual health services he himself might use, also explained how he wished he knew more about birth control services, saying:

I would like to have peace of mind knowing that there are opportunities for people to get birth control or IUDs [intrauterine devices] and stuff like that, so that I know that my female friends have the same level of access to resources that I know that I do.

Another participant, Leila, told a story of asking questions about STI testing (“just like frequency, where to do it, when to do it, things like that”) in a gynecology appointment at the health center where she did not feel that she received satisfactory answers. She wanted to know enough to understand when she herself might need testing, but also, as she revealed later in the interview, she wanted to feel informed in conversations with friends, a possibility that her doctor did not seem to acknowledge. Leila described:

I think I’m the type of person that likes to know everything just to tell my friends their options, things like that, and I think because some of the questions I was asking weren’t relevant to me at the time, they kind of just got brushed under the rug.

Her provider had assessed Leila’s individual situation and decided that since Leila was not currently at risk for STIs, she did not need further information about testing.

Comfort With Casual Sexual Health Conversations

Not every student feels the same level of comfort in discussing these highly sensitive topics with their friends. One student, Kayla, shared how she had felt anxious about seeking gynecological care for the first time and the power dynamics that might be at play in this situation. She explained, “I didn’t really think I could talk to other people about it, like it felt really...I don’t know in some ways, kind of shameful.” Earlier in the interview, she had shared how she had never talked with friends at university about sexual health services. She connected her discomfort with the topic to her cultural and familial background, explaining:

I think there’s a huge stepping stone for me to get over...I think just growing up the way that some Asian-Americans do, or people from fairly socially conservative backgrounds, just like the weirdness of the shame of talking about any of these things in general.

Throughout the interview, she described a shift in her comfort with the topic, saying, “at the time, I was just very uncomfortable talking to anyone about anything related to sexual health,” but later clarifying, “now I really feel nothing when I’m sharing this because I know it’s a common thing that happens.” While her willingness to discuss the topic changed over time, before her first visit to the campus health center, when she most needed reassurance, she could not turn to her friends for this support.

Another student, Renee, shared a story about accompanying a friend to the student health center to get emergency contraception because her friend did not feel like she could access sexual health information on her own. Renee explained, “before that [visit], I researched it for her because she was super uncomfortable researching it.” Later in the interview, she elaborated on how her friend’s limited past sexual health education made her friend less certain about what emergency contraception could do and anxious about researching this topic on her own. As Renee told the first author:

I said like ‘do you think you want to get Plan B?’ and she was sort of like,

‘yeah I want to, but I don’t really know how or whatever.’ She was really uncertain about it, not uncertain about how to do it, like kind of nervous, and so didn’t actually seem to know very much about how that would work.

Renee’s friend’s pre-college sexual health education experience did not equip her to understand how emergency contraception worked or the urgency of quickly gathering information about this topic, so, on her own, she might have never made it to the website, let alone the health center. A conversation with a friend enabled access in a way that the website alone could not.

Student-Led Sexual Health Education Efforts and the Role of ‘Peer Administrators’

Providers and university personnel occasionally recognized the importance of student-to-student communication in their discussion of how people learned about sexual health care services. However, they focused more on communication that happened through formalized student groups, rather than friendships. Students, many on a voluntary basis, either initiated or provided the bulk of the labor for the education efforts that university personnel described. The health center providers told the first author about student advocacy groups who had reached out to them for information and taken a leadership role in sharing that information with others. These students actively pushed for increased information for themselves and their peers.

In addition to these student-led efforts, providers also highlighted official university resources, many also involving the labor of students, but, this time, in more formal positions, what we call ‘peer administrators.’ All incoming students are assigned a mentor in the senior class who lives among first-years students and helps advise and support these students to ease their transition to university life. This is one of the main peer administrators that all students interact with. These peer administrators receive a stipend and free room and board as compensation for this work. In preparation for this role, they participate in extensive university training and, throughout the year, have routine check-ins with university personnel. Part of this training involves learning more about the university system and the resources available to students, information that they can then pass on to their first-year mentees.

Interview participants described these mentors as accessible sources of information. One student, Tiffany, described how she had needed emergency contraception in her first year, but was confused about whether she could get it at the student health center. When she asked her senior mentor, he reassured her of its availability, helped her look up information about where to go outside of business hours, and explained that any bill sent home would not disclose her Plan B use. She still had some uncertainties about whether it was actually free, but felt comfortable enough to seek the service and did not feel the need to ask her provider further questions.

First-year students might also have access to peer administrators through identity-based organizations on campus, such as groups centered around racial, ethnic, or sexual identity. Student leaders from these groups mentor first-years with similar identities and help them feel connected and supported in the larger community. These leaders are also paid for their work and learn about available resources like mental health and counseling services at the campus health center, making them a type of peer administrator. However, sexual health resources are not explicitly covered in these trainings. Students in this type of peer administrator role who participated in this study, though, still cited the recurrent trainings for the role as one reason why they themselves felt well-informed about campus health services, even if that training did not include specific information on sexual health.

One student, Jessie, who identified as LGBTQ, emphasized wanting these identity-based student advisors to have more information about the health center’s approach to queerness. She explained:

I think any medical provider, or any person that you’d see in this situation, should just emphasis the culture of the medical workplace of respecting your identities and being very clear about regardless of your queerness or transness, etc. that you’ll receive quality healthcare.

She described how in her training as a peer administrator, “even when we’re talking about [the campus health center] in general, there isn’t really an explicit statement that they’re making about ‘oh we are very equipped to deal with these needs.’” When asked about how that affected her experience seeking care, she elaborated:

It hasn’t materially affected me, but it’s definitely been something that I think about when I’m filling out forms and, it’s like, ‘who do you have sex with: men or women?’ and there’s just this very reinforcing binary thing. There’s just a lot of assumptions there that I just wish in general society didn’t have and obviously [the campus health center] continues that too.

Items like intake forms encode the heteronormativity of larger society into the student health center. Without an active effort from providers to counter these assumptions, this space remains heteronormative, something that LGBTQ students had to be aware of when seeking sexual health care and an area that where they wanted more information from official sources before visiting the center.

Official Sexual Health Education Workshops

In conversations about sexual health resources, health center providers returned most often, not to the long-term relationships of peer administrators, but to the sexual health workshops that happened during first-year orientation. To implement the workshops, the university partnered with a group of volunteer student health educators who taught a standardized script. Most of the year, this student organization focused on volunteering as health educators in local public high schools and middle schools. The organization was entirely student-run, with the exception of these workshops. Apart from a two-hour training in the fall and an hour-long discussion of the script in the spring, student leaders ran the rest of the organization’s training in how to teach health education. Outside this one-time orientation workshop, the educators did not work specifically on sexual health in the university community, though they occasionally engaged in some informal collaborations with other student groups doing that work. The authors would not classify these volunteer educators as peer administrators, given their limited training, lack of compensation, and short-term interactions with other students.

In the training that the first author observed, the group’s student leaders emphasized the use of a “peer to peer tone,” but in the workshops, the students’ role as educators superseded their identity as a peer. The student educator teaching a workshop sat at the front of the room and worked off a script, which steered the conversation through a pre-set list of topics. While there were interactive components, the script spelled out a clear objective and expected takeaway in each of these sections. The educator had to prevent major diversions from the script to fit within the allotted hour, leaving little room for student input.

Many interview participants remembered few details from these workshops, and several did not remember the workshops at all. Both the trainers in the workshop and the providers and university personnel recognized this trend, emphasizing the difficulty in summarizing and conveying useful information in this setting. These official actors imagined the workshop as a space to start conversations about sexual health and point students towards resources where they could later access more information. For some of my participants, this idealized version of the experience matched their actual memory of the workshop. As one student explained in her interview:

That [workshop] happened very soon after I got to [university], and so that was kind of my starting point for knowledge about [the campus health center], and it was from there that I went to the website to look at things just because the [workshops] were very clear about what services you could get here, which was really nice, services that I wouldn’t have thought that I could.

Another student described how she saw the impact of the workshop on larger questions around sexual communication on campus, telling the first author:

I wouldn’t have even really thought to even ask my friends about that kind of thing, if those workshops hadn’t set the tone of “it’s ok to talk about sexual health here”...like even though I didn’t know which specific sexual health services there were, it set this tone of “there are sexual health services available here and if you ask people about them, it’s ok.”

Both these students noticed gaps in information in the workshop, but still appreciated it for its tone-setting work and introducing them to the possibility of different sexual health care options.

That initial tone-setting work, though, did not have any significant follow-through after the workshop. With the exception of one type of peer administrator who focused on questions around sexual assault prevention, all other peer administrators at the university worked almost exclusively with first-year students. As students’ sexual experiences and, therefore, sexual health needs evolved over the course of their 4years, they could find themselves struggling to understand their access to newly needed services. When asked what she recalled about the workshop Fiona said:

I don’t know if I particularly cared about knowing that much, just because I was in a long term, long distance relationship, and so I might have just tuned it out because I was like “Oh this isn’t applicable to me”, even though, quite obviously it is applicable to me later in life.

Another student, Stevie, expressed a similar sentiment when he told the first author:

I think people’s sex lives change throughout the course of college, whether that be like they’re having a lot more sex or a lot less sex or they’re having sex with different types of partners, whatever it is, I don’t think that people’s sex lives look exactly the way they did 4 years ago, 3 years ago, and with those kinds of changes comes a need to continue talking about...like sexual health services and all the different cultures surrounding sex.

The tone-setting influence of a first-year sexual health workshop might make students more confident in searching for that information early on, but that work could only go so far without follow-up, particularly as students found their needs changing.

Discussion

When looking for trusted information about sexual health resources, the students interviewed often turned to their friends, where caring relationships enabled the sharing of logistical and experiential knowledge about sexual health services. The students asserted their desire to acquire information about the health center for themselves and their communities, but having casual conversations about sexual health was not a universal experience. Some students felt shame and stigma when discussing the topic with peers. Younger students utilized ‘peer administrators,’ with whom they had durable and trusting relationships, as a source of information. However, at this university only the volunteer student health educators, who did not have long-term interactions with the students that they worked with, had an explicit focus on sexual health. These educators relied on a script and occupied a position of power in the workshop that limited the potential for genuine relationships with the younger students. While some of the student interview participants mentioned the useful tone-setting impact of these early interactions, these workshops did not provide space for sustained relationship-building and did not provide long-term support as students’ sexual health needs evolved.

Sasha’s and Skyler’s experiences of learning about sexual health services from friends demonstrate the interplay that Byron describes between informal sexual health promotion in friendships and official resources.¹² In Skyler’s case, these informal conversations provided insight into experiential details of STI testing at the health center, an important influence on their comfort level in seeking this service. Like Byron points out, conversations with friends, rather than just offering factual information, provide young people with a space to reflect more deeply on sexual experiences.¹² While Skyler’s concerns about judgement in STI testing did not necessarily constitute a sexual experience, in their conversation with their friend, they were not simply looking for biological information. Their trust in their friend meant that his positive experience helped counter a resonant and negative personal experience and gave them the comfort necessary to pursue testing themself. In Sasha’s case, the closeness and trust formed in cohabitation, a lack of judgement, and equal disclosure from her suitemates allowed for the opening of a privacy boundary which ultimately benefited Sasha, similar to the communication between sorority women described in Hernandez’s study.¹⁹ With both Sasha and Skyler, trust and open communication between friends acted as a form of social capital.

Peer administrators who built longer term relationships with their mentees could replicate some elements of this trust. While their communication with younger students was not reciprocal and intimate in the same way as friendship, they could still create non-judgmental spaces.^12,19 Unlike formal sexual health interventions, such as websites,²⁵ email exchanges,²⁶ or Public Service Announcements (PSAs),²⁷ peer administrators already had an authentic shared identity with the students that they worked with and could facilitate more active conversations about sexual risk. In conversations with peer administrators, students could test different ways of communicating about that risk without the judgement of a medical professional.¹⁹ They could also seek out knowledge from these sources of official information who they trusted when they felt most at risk, rather than having to recall information from PSAs they felt were less relevant at the time.²⁷ Peer administrators can bring trust similar to that experienced in a friendship, the support of the university, and official resources to their interactions with their advisees.

Jessie’s experience also revealed the potential for peer administrators to speak to concerns specific to a student’s identity. Similar to Baker and Beagan who describe how attempts to maintain neutrality in a clinic uphold a status quo of heteronormativity, Jessie pointed out how assumptions about binary gender that exist in larger society structure the clinical encounter.²⁸ She advocated for a medical space in which providers actively supported LGBTQ students and did not leave the labor of improving the encounter to the patient, another issue identified by Baker and Beagan.²⁸ Jessie’s reflections on what she wanted more of in her training as a peer administrator reveal how peer administrators can help shift the official university narrative while connecting to their mentees through shared experiences.

Shared experience with peers can help individuals cope with a larger societal failure to acknowledge young people’s sexual citizenship.²⁰ This resource, though, is not always available to young people, as Kayla’s story reveals. Kayla also felt anxious before her appointment like Sasha and Skyler, but her discomfort with discussions around sex did not allow her to access social capital in the same ways that they did. Institutional barriers like cost, stigmatization of STIs, and limited time for seeking health care increase the importance of family messaging in sexual health decision making.¹⁵ Students’ familial and cultural background shape their comfort with these topics and, therefore, their ability to access support from their social networks. Kayla’s experience of her ethnicity and familial taboos related to discussing sexual health should not be taken as a cultural universal due to “fixed ethnic traits.”²⁹ Rather, her hesitancy indicates a local and somewhat culturally-mediated experience of much larger decisions around youth sexuality. When the state “denies young people’s sexual citizenship,”²⁰ young people experience sexual shame, and sexual communication becomes much more difficult, both in the context of sexual and romantic relationships and in more platonic, but equally as important, friendships. A stigmatizing approach to youth sexual health in other institutions meant that different forms of communication around this topic in Kayla’s family had a larger impact on her.

Sexual health knowledge, though, is often portrayed as an individual responsibility rather than a community project, as seen in Leila’s experience. The limited recognition of the role of friendships in sexual health promotion that Byron describes foreclosed the possibility of Leila seeking information for friends in her appointment.¹² Despite the importance of peer norms and perception of community risk in decision-making about STI prevention,^18,30 the emphasis in the health care setting remains firmly on the individual. Health care workers often rely on biomedical paradigms which tend to focus heavily on the individual while ignoring the impact of broader relationships.¹⁴ Within this paradigm, young people’s intimate conversations about sexual health services with close platonic friends occupy a difficult to categorize space, meaning that health care providers often underestimate these conversations as a component of the information landscape.

If providers see sexual health as an individual responsibility, they can also overlook the importance of peer educators’ lasting social relationships with other students. The orientation workshops were the one official university program that addressed access to sexual health resources. Yet, the primary objective of information provision within a short time frame undermined the establishment of deeper relationships that could facilitate trust. Though not as intense as in other sexual health education settings, hierarchies still existed in these workshops. In traditional classrooms, these hierarchical relationships between teachers and students can limit the communication necessary for sexual health education.³¹ While the student educators did not have the formal power of a paid teacher, they still occupied the ‘teacher’ role in the workshops, complete with the difference in status between them and the first-years. These are the traditional peer educators of public health, people who are not friends and are not in a position to create durable relationships.¹² The positioning of these students as official educators also marked them as more knowledgeable and less risky, potentially making the less knowledgeable students that they were teaching seem riskier in comparison.¹³

In the case of Renee and her friend, we saw knowledge sharing outside a formal peer education program. While Renee did draw an informed versus uninformed distinction between herself and her friend like the youth health educators in Shoveller and Johnson’s article,¹³ her conversation with her friend happened in the context of a relationship built on trust. Rather than crafting division, this conversation in a more open-ended space allowed Renee to serve as a “friend educator” rather than a traditional peer educator.¹² Even if medical settings emphasize individual risk management,¹⁴ students like Renee and her friend work in community to negotiate the systems required to fulfill that responsibility.

Limitations

This study reflects findings from one university and cannot be generalized to all United States college campuses. This particular university provided a comprehensive set of reproductive and sexual health services at no or low-cost to students. At other universities with less robust options for care, additional barriers might exist. Unlike Hirsch and Khan’s ethnographic study, which is also set in one university, our research does not utilize quantitative surveys, which could have provided additional context for the findings and allowed quantitatively testing some of the trends identified in the qualitative data.²⁰ Additionally, this study is smaller in scale than Hirsch’s and Khan’s work. Given the focus of this article on sexual health care seeking, there were also fewer opportunities for participant observation. The findings rely primarily on a limited set of student reflections about past conversations and experiences.

We do not claim, though, that the voices in this study, the researchers included, represent an all-encompassing view of sexual health care seeking at a university-setting or even this particular case study, rather these moments are one of many possible snapshots of student experiences. The inclusion of longer quotes from our student participants are intended to emphasize the ways in which this work is not complete and requires other differently positioned, partial perspectives.³² The work that these students did to navigate and challenge the systems around them should appear as a possibility, one that begins the work of inspiring new approaches to sexual health.

In this article, we center peer relationships and do not explore other important factors in sexual education, like conversations with family and parents, popular media, and sexual education in high schools. The larger ethnographic study that informs this article discussed the role of these other factors, but in this article, we intended to highlight peers, an often-overlooked source of sexual health information and socialization. As Hirsch and Khan point out, parental relationships, public institutions, and sexual education policies all have a role to play in developing the sexual citizenship of young people.²⁰ Future studies should explore the interactions between peer and parental relationships and the impact of social policies on communication between peers to demonstrate how these factors work together.

Kayla’s description of her changing feelings around casual conversations about sexual health further reveals the particularities of the research setting. Signing up to conduct an interview with a heavy focus on sexual health requires a degree of comfort with this topic that likely deterred people with stories like Kayla’s from participating. While many of the participants did not express discomfort about discussing these topics with their friends, this study utilized a convenience sample, so students included were likely those most comfortable discussing sexual health in both an interview and more casual interactions. There are most likely students that share Kayla’s initial experience of shame who did not choose to participate because they still do not feel comfortable sharing those experiences. The interview setting might have also filtered the reflections that students chose to share even more, as the presence of the researcher hinted at the possibility of judgement. Particularly with the topic of sexual health, where knowledge connotates a moral judgement about riskiness, students might have felt pressure to appear knowledgeable, safe, and morally ‘good’.¹³

Implications and Conclusion

Universities that want to promote the sexual health of their students can build on existing peer relationships by investing in peer administrators who focus on sexual health and work throughout the year in a variety of spaces. Peer health educators already exist at a number of universities, some with a specific focus on sexual and reproductive health and others with a broader focus on student well-being and health.³³ These programs are promising, but it is critical that these educators receive regular training and compensation from the university to truly become peer administrators. Compensation would also allow a wider range of students to participate and for the university to reach more of their student body. The emphasis of these peer administrators should also expand beyond one-off informational events or workshops and include more informal interactions in their regular social groups. While these students should be equipped with detailed information about things like insurance coverage, confidentiality, and the scheduling process at the student health center, in addition to more general sexual health information, their role should center around creating a campus culture where people feel comfortable discussing these topics in the first place.

In institutions with non-health specific peer administrators already in place, training of these students should include information about supporting other students with more routine sexual health concerns, in addition to responding to sexual assault. The long-term mentoring relationships that these peer administrators cultivate ground them in the student community, while specific training on sexual health would give them the tools to assist students who trust them. Additionally, this training should include a focus on the needs of LGBTQ students to allow peer administrators to proactively answer questions about the health center’s approach to sexuality and gender.

Universities should promote information sharing among friends and informal social networks. Rather than imagining sexual health as an individual responsibility, sexual health providers and promotion programs can emphasize the community project of sexual citizenship in their conversations with students.²⁰ Conversations in both the clinic and educational workshops can center the role that students can play in helping their friends and proactively share information with all that would be useful to a wide range of identities. Universities can also encourage more tone-setting events like the sexual health workshops discussed in this article. While a one-off training can only go so far, recurring events can set a sustained tone that sexual health is a priority for the university and that resources exist for care in this area.

Finally, the interactions between informal communication and official resources indicate a role for story-telling in official university communication. Student health center websites should include direct stories from students to acknowledge the ways in which decisions around sexual health care also encompass experiential questions like the tone providers take in interactions or whether or not students felt affirmed in their sexuality and gender identity. Health centers should prioritize including voices from LGBTQ+ students, students of color, and other students who might have reason to expect stigma in a health care setting.^28,34 At the same time, university health centers should engage campus organizations centered around these identities to partner in this work and create reciprocal relationships.

Larger societal and biomedical perceptions of youth sexuality and risk impact students’ ability to develop and deploy their social capital to improve their sexual wellbeing. Despite these challenges, conversations between friends and the support of peer administrators offer possibilities for community support of positive youth sexuality and students’ sexual citizenship.

Author Biographies

Veena Muraleetharan graduated with a Bachelor of Arts in Anthropology from Yale University in May 2020. Her research interests include reproductive health, young adult sexual health, and medical anthropology. This is her first publication.

Marie A. Brault is an associate research scientist and medical anthropologist at the Yale School of Public Health, Department of Social and Behavioral Sciences. Her research focuses on adolescent and young adult sexual, reproductive, and mental health.