College Students’ Sexual Health: Personal Responsibility or the Responsibility of the College?

Abstract

Objective

This article examines students’ perceptions of individual and institutional responsibility for sexual health so institutions can better provide for the needs of their students to increase academic success and healthy relationship outcomes.

Participants

Students from two-and four-year colleges in one state (n = 78).

Methods

From May through November 2010, the authors used go-along interviews to examine students’ perceptions of resources for sexual health on their campuses.

Results

Participants believed that it is the college’s responsibility to provide resources and the responsibility of students to access resources. Participants at two-year schools wanted referrals to resources, whereas participants at four-year schools expected resources to be available and emphasized the importance of a supportive community.

Conclusions

Students at two- and four-year colleges have different expectations of their institutions; by making resources and referrals for sexual health available, colleges can better serve their students, which will result in improved health outcomes.

“…I would say yes, the university is responsible for the well being of its students. It is responsible for helping develop all of its students in ways far beyond just giving them facts about subjects…the main objective of a college, university is…about developing the students and making them versatile people that can adapt to situations in the real world…the well being of students is a big piece of being able to develop them as people. Sexual education is a fairly basic thing for a mature person to have.”

Introduction

College students are often transitioning from their family unit toward independence. The period between age 18 and 25, “emerging adulthood,” is defined as a transition period in which individuals do not feel like adolescents yet do not feel fully adult; during this stage individuals are exploring and developing their adult identities, and they experience themselves in a state of flux.¹ This life stage is characterized by acceptance of personal responsibility, including responsibility for one’s sexual health and decision-making.

College-aged youth are at increased risk of negative outcomes related to sexual health compared to the rest of the population. Sixty-four (63.6%) percent of high school seniors report being sexually experienced, with approximately half reporting their sexual debut occurred during the traditional college years.² Emerging adults experience a disproportionate risk of negative sexual health outcomes compared to all other age groups;³ with 29% of this population reporting not using condoms, and 11% reporting not using birth control,⁴ it is not surprising that over one-third of new cases of gonorrhea and Chlamydia occur in young adults between the ages of 20-24.⁵

According to the CDC, the higher prevalence of negative sexual health outcomes among adolescents and young adults may reflect multiple barriers to accessing quality preventative services, including discomfort with facilities and services designed for adults.⁶ In a study by von Sakovsky, findings showed that when they needed information on sexual health, 18-28 year olds did not know how to find the appropriate resources to answer their questions.⁷ Without access to this information, it is less likely that they will enjoy healthy sexual relationships, and they may suffer negative academic outcomes that have long-lasting repercussions.⁸

The United States (US) Department of Education reports that 65% of high school graduates attend college, including both two-year and four-year post-secondary institutions.⁹ For this population, sexual health concerns can be detrimental to academic achievement.^10,11 For example, 61% of women who have children after enrolling in community college drop out before earning a degree.¹² Despite the documented negative academic outcomes associated with sexual health concerns, post-secondary institutions may not prioritize preventive measures related to sexual health as highly as they prioritize other topics (e.g., influenza, responsible alcohol consumption). Although 60% of post-secondary institutions have either a campus-based health service or an established linkage with a community-based clinic,¹³ many students are not accessing the information they need to proactively protect their health. As of 2009, only 52.5% of college students reported receiving information from their college on HIV and sexually transmitted infections (STIs), and less than 40% of college students indicated they had received information on unintended pregnancy, despite the fact that sexuality education has been found to improve health outcomes for young adults,¹⁴ and that a holistic approach is necessary to achieve optimal adolescent well-being.¹⁵ The Sexuality Information and Education Council of the United States (SIECUS) has issued a statement that it is the responsibility of those professionals serving young adults to “provid[e] accurate information and education about sexuality, and [to assure] access to sexual and reproductive health care”.¹⁶ Included in the Healthy People 2020 objectives is increasing the proportion of postsecondary students who receive information from their institution regarding unintended pregnancy, HIV, and STIs (ECBP-7.7, 7.8).¹⁷

Research Aims

The link between people and the environment is the basis for a socio-ecological approach to health.¹⁸ The Social Ecological Model provides a framework for taking into account the context of environment in issues of accessing resources for sexual health, and locates health behaviors in on the context of influences at multiple levels (i.e., individual’s perception, influence of friends and peers, community norms, accessibility of institutional services, and politics of the society).^19,20 Greene, Wheatley, and Aldava posit that an individual’s position in an educational institution impacts her acquisition of cohort norms. They have reported that college students and non-college students hold different beliefs;²¹ it is possible that two-year and four-year college students have different beliefs as well. To our knowledge no studies have explicitly examined students’ perceptions of responsibility for sexual health resources. By qualitatively examining participants’ views on personal responsibility and the role of the college in relation to sexual health resources, this research aimed to identify how college health services can best meet the needs of students and to determine where students prefer to seek resources for sexual health. To provide for the unique sexual health needs of these emerging adults, institutions need to have a clearer understanding of students’ expectations.

Methods

Study design

“Go-along” interviews consist of participants leading a researcher on one-to-one tours of their environment, and are well-suited for addressing sensitive health topics²² and exploring local resources for health.²³ Through guided questioning and interacting with participants’ environments, the go-along method provided rich data resulting from participants sharing their experiences and perspectives. Interactive qualitative methods allow the researcher and participant to jointly contribute to identifying new knowledge; this interactive dance is not possible with other approaches such as self-report questionnaires. Further, the sensitive nature of the topic warranted interviews rather than focus groups because individuals could interact in one-to-one discussions rather than speak up in a group context; a group go-along tour would also be less feasible to undertake. The research team conducted go-along interviews on five college campuses in one state from May through November 2010. Our previous research experience informed the development of the interview guide, which followed a recommended format of warm-up questions, substantive questions, and a wrap-up question probing for anything else the participant felt was important to share. The interview guide went through revisions based on research team edits as well as feedback from external experts in college health and qualitative methods.

Recruitment

After approval from involved Institutional Review Boards, recruitment began on the five college campuses. Participating colleges included one two-year metropolitan institution, one two-year non-metropolitan institution, one private four-year metropolitan institution, one large public four-year metropolitan institution, and one public four-year non-metropolitan institution. Recruitment efforts included “tabling” in high traffic areas (e.g. student union) to attract interested students at all five campuses and fliers posted in public spaces on all five campuses, as well as email announcements generated by campuses’ Health Service on two campuses and targeted emails to specific groups of students (e.g., varsity athletes and members of Greek life) on one campus. Several participants were also recruited through snowball sampling, after their peers informed them of the study. To be eligible, participants must have been 18-24 years old at the time of the study and never have been employed by nor volunteered for the campus health service. On each campus the research team intentionally sought gender balance and oversampled students of color in an effort to obtain diverse viewpoints.

Data Collection

Participants provided informed consent by reading a consent form, having the opportunity to ask questions, verbally confirming that they understood the contents of the document, and signing the consent form. Each go-along interview was conducted by one member of the study staff walking through each participant’s campus, on a tour guided by the participant. Interviews were conducted using a semi-structured interview guide, with four questions related to sexual health resources (see Table 1).²⁴ To begin, participants were asked an initial “warm-up” question, which allowed them to better understand the nature of the go-along interview. The primary questions asked as a part of the go-along technique provided a loose framework for the conversation and tour. As tour guide, the participant could organically describe the campus environment as they perceived it and frequently include insights not specifically prompted by the interviewer. Participants were not asked specifically about personal responsibility, but many volunteered their perceptions on this topic when responding to other interview questions. Interviews lasted an average of 48 minutes (ranging from 24 to 88 minutes) and were digitally recorded using a lapel microphone; participants received a $50 gift card. The audio files were transcribed by a professional transcription service and verified for accuracy by members of the study team. Additional details regarding the study’s design, recruitment strategies and data collection procedures are available elsewhere.²⁵

Table 1.

Semi-structured interview guide.

Warm-up question: If I wanted something to eat, where could I find a snack on this campus?

Primary questions How do you find information on sexuality, or sexual health at [name of college]? If you had a sexual health concern – say a friend came to you and thought they had an STI – what could [name of college] do to help? Do you have a clear idea of what [name of college] wants for students in terms of their sexual health? You’ve given me a lot of examples of sexual health resources at [name of college]. Can you tell me what your top five most important or helpful resources on campus would be, including what is actually here and any other ideas you might have?

Analysis

The qualitative data were quasi-inductively coded using ATLAS.ti,²⁶ and were examined for similarities and differences by sex, race/ethnicity, campus, and type of school (two-year and four-year). Quasi-inductive coding employs a mix of structural coding to address the research questions using pre-determined codes, and data-driven coding to examine the data through an iterative process.²⁷ This approach honors the rigor of qualitative research while allowing the participants’ voices to guide the findings. This method allowed for participants’ views of the significance of personal responsibility to guide our research team to analyze the data through this lens.

To ensure coding rigor, multiple members of the study team independently coded 10% of the transcripts (n = 8), and subsequently examined and compared their coded text for coding discrepancies and completeness. When a discrepancy arose, the two coders met with two other members of the study team to discuss the discrepancy and refine or clarify the code definitions. At the conclusion of the first round of coding, the coders re-read each transcript and affirmed code consistency. With ongoing research team discussions of code definitions and our double-coding processes, we are confident in the reliability of our coding.²⁸ Two codes were developed to specifically address responsibility for sexual health issues (i.e., “personal responsibility” and “responsibility of the college”). The present research is based on an analysis of data coded with either of these two codes, as well as with nine additional codes related to perceptions of responsibility and accessibility of services (e.g., “perceptions of campus culture” and “how colleges should spend money on sexual health resources”). Themes were examined across gender, race and type of college (2-year vs. 4-year). Substantive differences were apparent for each type of college; these results are described below. No differences were observed by sex or race/ethnicity.

At the conclusion of analysis, members of the study team contacted three participants who had agreed to be contacted with a summary of the findings. Participants were contacted by telephone and were asked to confirm statements quoted from their interviews, as well as the general findings of the analysis. Of the five participants who the study team attempted to contact, two were unable to be reached after multiple attempts. Each of the three participants who engaged in the member check provided feedback regarding the general findings presented from the analysis; all stated that the summary reflected their individually-shared perspectives.

Results

Participant Demographics

Participants in this study were 78 students currently enrolled in post-secondary education on five two- and four-year campuses in one state in the United States. The sample was composed of 38 women (49%) and 40 men (51%), aged 18-24 (average 20.6 years) and represented each class year. Within the sample, 67% (n = 52) self-identified as white and 33% (n = 26) identified as individuals of color, including Hispanic and multi-racial students. Participants included members of the following communities: transfer students, commuters, dorm residents, LGBT (lesbian, gay, bisexual, transgender) students, Greek life, military, intercollegiate athletes, and pregnant and/or parenting students. Participants included both sexually experienced and sexually inexperienced individuals. Sexual experience and sexual identity were not formal questions and were only discussed when initiated by the participant.

Qualitative Themes

The theme of personal responsibility for sexual health resources was evident in the students’ shared perspectives. Three descriptive sub-themes organized these findings: 1) perspectives on seeking sexual health resources during emerging adulthood, 2) emerging adults’ perspectives on sexual health resources available via their college, 3) emerging adults’ financial considerations relevant to sexual health resources.

Perspectives on seeking sexual health resources during emerging adulthood

Participants described themselves as adults, and as such they embraced the responsibility to access sexual health resources when needed. When considering access to sexual health resources, students focused on their coming-of-age as a reason they exercise their personal responsibility to make decisions related to sexual health independent of the values of their families or institutions. A participant explained, “I think at this age, individuals need to take most of the responsibility, if not all of it. We’re all over 18, we’re all growing older, and the university can provide the resources, but…I think it’s up to each person to do what they think is best for themselves.” One student astutely captured the catch-22 of sexual health education for his generation: “Yeah, there’s definitely a need for more sexual education. No one wants to talk about it while you’re growing up because you’re a kid, but once you’re an adult they think you already know it.”

While acknowledging the broader cultural sensitivity of issues related to sexual health, students felt similar to one who commented that it is “the person’s responsibility [to pursue sexual health resources] and we’re old enough now where I think everyone should feel comfortable asking questions if they have them and not be nervous about it.” Students expect to be treated as adults as they make decisions relating to their sexual health, and they emphasized their perspective that college students are on a path of maturing into capable adults. One participant explained, “not that they shouldn’t be able to look after themselves, but just [support with] a first step on a transition on how to go seek out information for yourself because a lot of people are on their own for the first time right now.” As emerging adults transitioning from adolescence to adulthood, both two-year and four-year students want to be supported by their institution. One two-year student pointed out that he believes the college “probably should play a role because a lot of college students are just coming out of high school, just coming out of home, and someone’s got to look after them.”

Unique to four-year participants was the concept of the role of the college as offering resources and support, and empowering students to decide for themselves if and how to access those resources. It was clear to participants attending four-year colleges in this study that the institution should be responsible for “providing the resources.” The students appreciated when they felt like the institutions were “leading us in the right direction” on their path toward needed sexual health resources. A participant from a four-year institution explained that the college could show respect for students’ emerging adulthood by providing access to resources and trusting that students will take charge of their own health. For students at four-year institutions, there is a belief that attending college is part of lifelong learning; “that’s the purpose of an institution like this, is…education, not just on a school subject level…just on anything on life and you know, sexual awareness is definitely a key component to life and being knowledgeable of that is definitely…something everyone needs to have.”

On all campuses participants reported that their institutions had a responsibility to be welcoming to and supportive of LGBT students. One student praised his institution as one that “…welcomes your own individuality. And to be able to have like a week where LGBT students can basically come out of the closet, or be represented and get support instead of ‘boos’,” as an example of the supportive community four-year students expect.

Across the diverse sample represented in the study, it was important to participants that all of their peers feel supported on campus. Students emphasized the need to respect each other’s values, and believed that the institution has a role to protect students from negative outcomes. One student’s description was supported by others, “It’s kind of like, yes, if your beliefs say that you can’t do it, all the power to you…But if you want to be sexually active, whatever, do it up.”

Emerging adults’ perspectives on sexual health resources available via their college

Participants viewed providing access to sexual health resources as the responsibility of the college, but emphasized that resources should be made available in a way that requires students to take the initiative to access them. At one four-year school with extensive resources for sexual health, a student stated, “I like the fact that they’re not pushing it on us too much, because I think that would just get annoying and upset people.”

Participants agreed that sexual health resources provided by the school would be beneficial to their well-being and would facilitate use of sexual health resources by students. When discussing the lack of resources for sexual health—including information, educational opportunities, referrals, and community support—a student remarked, “It’s sad that [students] really don’t have a resource for that.”

When describing sexual health resources available through a particular institution, students’ expectations differed for each type of college. Students from four-year schools consistently expressed an expectation that the physical resources for their sexual health, such as condoms and STI and pregnancy tests, be available on campus; likely because physical resources were assumed by students to be a given, four-year students focused on ensuring a supportive campus community as a major responsibility of the institution. A student at a four-year college explained, “It’s good for them to make you aware of the resources, and to try to keep people from feeling guilty for something, or feeling like they’re alone.” In the case of personal crisis situations, four-year students reported knowing how to access the necessary resources, but as one student shared, “it would be nice to think I had back-up at the university.”

Participants on two-year campuses described the role of the college differently than participants from four-year campuses. Students at two-year schools reported wanting institution-provided access to basic information such as pamphlets on sexual health topics and referrals to community resources. One student explained, “I’m not saying it is [the institution’s] job to have clinics and hand out medicine or birth control…but if they could help you find out where to go, that’d be just as helpful.” Two-year students considered post-secondary school to be a place “mainly to learn, to get degrees and stuff like that, not to be tested [for STIs].” A student at a two-year college reported that, “if this were a school where you lived on campus, if I lived here, then it [sexual health resources] would be definitely something I would expect it to have, because where I live that is where I could get those resources.” But as a student at a community college, he feels that he is just on campus for the classes and “I don’t hold [the college] as responsible” as what would be expected of a four-year institution.

For participants at two-year institutions, there was an expectation that the physical resources for sexual health (e.g., contraceptives, sexual health information, testing) would not be available through the campus. A two-year student reported that, “they don’t have it and I’m still here. It doesn’t bother me because I can always go to a clinic.” For metropolitan two-year students, the possibility to access resources beyond the borders of the campus decreased their dependence on the institution for provision of resources. A student at a two-year metropolitan college said that “it would be nice for some people to have, but I don’t think it’s something, because there’s so many government buildings and places you can go if you really need [condoms], and they’re not that expensive anyways.”

Without expecting a clinic on campus, two-year students expect the college to be prepared to guide students to resources for sexual health in the larger community. Students offered ideas on how the college could provide referrals to community-based resources when the resource was not available on campus, “they should have something that lists the clinics. They should probably have some sort of information, or a person there that knows enough to talk people through questions they might have if they have an illness, or just questions in general.” Students on one campus perceived a lack of sexual health resources, and described the situation as one in which the campus was not meeting the needs of its students, “I would come here to try to get some information, and obviously they don’t have any, so this isn’t a place that I could turn for some of my community needs.”

A small minority of students expressed that they do not depend on the school for sexual health resources because they do not want to mix their personal and academic worlds. One student described the separation as preferring “to keep my school and my private life separate as much as possible.” Speaking with an air of prior disappointments, one four-year student explains, “I guess I don’t really expect too much because I can get most of it on my own. I am a junior, so I don’t depend too much on the school other than for classes and the occasional lunch in the [cafeteria].” A two-year student explained that she “wouldn’t want to bring that [sexual health resources] in to the classroom setting because I just think [the college is] there to help me learn.”

Emerging adults’ financial considerations relevant to sexual health resources

Students at both two-year and four-year institutions identify the financial burden of attending college as a reason that the institution should be responsible for assisting students in accessing sexual health resources. Students want to benefit from subsidized resources: “you spend enough on student fees anyway; you should be able to get free condoms,” as well as easy access to information and referrals: “because we come here and pay so much that they should be helping us out a little bit with everything, all the issues we have.” Students believe that financial burdens being faced by two-year institutions are the reason for limited sexual health resources availability, “I think that they want the resources available, obviously, but I know budget is [a] huge [issue].” One student on a metropolitan campus noted that, “I think [health service] would be a nice service to have,” but as the larger community offers sexual health services he recognized that the institution made a necessary decision to fund other campus programs.

While recognizing the financial reality that prevents the school from providing sexual health resources, participants did not mask their disappointment. A student said, “it’s completely about money. Like I said, they’re talking about cutting funds for the daycare and just getting rid of it, and doing cuts on teacher’s pay and stuff like that, so especially with the rise of [numbers of] students, they don’t have enough money to supply things for every student. It sucks.” Another student on the same campus agreed and offered a suggestion for a low-cost way to support students’ sexual health, “The school is a business. I can understand why we don’t [have sexual health resources], because it’s a smaller school…It would be good to have information here so we would know who to contact…or somebody we could talk to that’s familiar with what’s going on everywhere else.”

Commentary

Two-year institutions differ from four-year institutions in the availability of resources and the expectations of students. The two-year colleges in this study had more limited offerings than the four-year colleges, each of which had a full-service health service on campus to address varied sexual health concerns. To better serve students on two-year campuses as they transition to adulthood and pursue career preparation, the college should connect them with community resources to address their sexual health needs. In certain circumstances this was happening, yet frequently the students were not aware of available pathways to resources via the college. Students from two-year colleges believed that referrals to community resources for sexual health were sufficient—yet even when these were available, participants were often unaware of them. On the other hand, four-year students expect that they will be able to meet their sexual health needs on campus, and want to feel emotional support from their college community. On four-year campuses students specifically mentioned support and acceptance of LGBT students. Participants at four-year colleges consider knowledge of how to maintain sexual health an integral part of their complete education. Four-year students may spend more time on campus than two-year students, and as such may consider it their main community and therefore expect more support from that community.

Though the actual resources available for sexual health may influence student behavior, interpretive interactionism assumes that an understanding of students’ perceptions of resources is crucial to inform the creation of effective health promotion interventions, especially because the period of emerging adulthood is a turning point in their lives.²⁹ These frameworks suggest that to understand the sexual health help-seeking behaviors of college students, it is necessary to understand their perception of the college environment; a well-resourced environment perceived negatively might not be accessed by that student and similarly, an under-resourced environment students’ perceive as trustworthy could become a vital resource and referral mechanism to needed services. Students understood the responsibility of the college to be both collecting resources for sexual health and making students aware of available products and services; students perceive their role to be making decisions for themselves and taking the initiative to access those services they feel they need.

The findings of this study affirm Arnett’s description of emerging adulthood³⁰ as a period during which individuals move towards independence. Without prompting, many participants emphasized the sentiment that 18-24 year olds feel like neither youth nor adults. Individuals in this life stage require support to have positive sexual health outcomes, particularly due to the insufficient (sometimes nonexistent) sexual health education they receive during adolescence. We expect that these findings are relevant to other sensitive health topics, such as substance abuse or mental health concerns. In terms of sexual decision-making, the study population’s perception of themselves as undereducated supports the research demonstrating this group as a risk demographic and may partially explain the high proportion of negative outcomes experienced by this group.

Students consider sexual health to be an important component of general health, and prior research supports the importance of sexual health for academic achievement;^31,32 they generally do not view sexual health resources as political, nor as optional products and services, particularly at 4-year colleges. To enhance the wellbeing of students and assist them through their emergence as adults, students want post-secondary institutions to provide education on sexual health, resources for sexual health when feasible, and links to community sexual health resources.

Limitations and strengths

This study may be limited by its lack of exploration of resources available in the surrounding community. A complete picture of community resources for sexual health may impact students’ perspectives on the responsibility of the college. When considering these findings, it may also be important to note that actual resources available in the environment were not measured. The insight of campus experts on available resources for sexual health may have enriched our findings.

Since we conducted interviews on a small number of campuses in one region of the country, application of findings (i.e. transferability) beyond our study sites may be limited and should carefully be considered for college campuses elsewhere. Themes were analyzed with consideration for possible differences by the participants’ sex and race/ethnicity, but not according to other characteristics. It would be interesting to examine the ways in which these themes might vary by other factors such as student religious and political affiliation. Though this study includes the perspectives of culturally- and ethnically-diverse students, further exploration is necessary to understand the perceptions of students in other parts of the country.

There are many strengths of this study. With 12-18 participants on each campus, we are confident that data saturation was reached within and across the campus types. Further, the research settings were diverse with regards to college type, sector, location and size. In particular, it is among the first to examine sexual health issues in two-year college students. With a diverse sample of students from each of these institutions, this study offers a rich understanding of the many perspectives present on campuses.

As in any research, the authors worked to minimize personal biases and recognized the inherent influence researcher perspective brings to all research, including qualitative methods. The research team was comprised of white females with professional backgrounds in public health, nursing, nutrition, college health, and reproductive health. It is possible that these attributes might have affected recruitment, interviews and data analysis. However, specific actions were taken to ensure the rigor of this qualitative inquiry, including documenting carefully the data organization and coding processes, providing representative quotes to strengthen credibility, and bringing findings back to some participants (i.e., member checks) for their assurance that the synthesized findings remained representative of their voices.

Conclusions

With the findings from this study, the authors recommend that campus health care infrastructure adapt to optimally provide services to students. For institutions without a Health Service, we recommend that Student Services or a similar department research available community resources and create and maintain a resource and referrals list. This compilation of local resources—when campus-sponsored resources are unavailable—should be advertised to students and made accessible virtually as well as through a counseling department. College Health Service or Student Services should make educational information regarding sexual health available to all students in electronic and physical forms. All institutions should foster an environment that supports students during their transition from adolescence to adulthood, with special focus on students that may be at heightened risk of stigmatization of negative outcomes, such as LGBT, nontraditional, or pregnant/parenting students.

College students consider sexual health an integral part of general health, and want to be supported and guided by their trusted campus resources as they navigate this important piece of their adult life. SIECUS has made a clear statement that, “becoming a sexually healthy adult is a key developmental task of adolescence,”³³ and as such campus health services, guidance departments, and offices of student life are positioned to positively influence both academic and life outcomes by ensuring that resources for sexual health are available and accessible to students. We recommend further research with students who have experienced negative sexual health outcomes in order to gain a better understanding of how the college could support students during sexual health crises, and how the college could help prevent harmful sexual health experiences.

We recommend use of multi-media approaches to inform more members of the diverse student body of existing resources, and when possible to offer referrals to trusted community resources for sexual health. To better serve four-year students on their path to healthy sexual expression and academic achievement, we recommend communicating frequently—and with varied mechanisms—about the existing sexual health resources and emotional supports that exist on campus. In cases when resources are not available on campus, we strongly support increased funding for this crucial component of student wellbeing.

In conclusion, students see the primary role of the college as providing resources or information regarding sexual health resources, and then leaving it up to the students to decide whether to pursue them. The Ottawa Charter explains that without being able to exercise control over their determinants of health, people cannot achieve their fullest health.³⁴ Health promotion efforts on campus should effectively increase the options available to students to exercise control over their health, and to make choices conducive to sexual health and wellbeing.