“Sexual Health is dead in my body” (Zoran, 23, male Kurdish asylum seeker)
Our results demonstrate that refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands have a fair good understanding of the different aspects comprising sexual health. Moreover, they are also to identify a variety of determinants. Some of these determinants are important requiring consideration in future sexual health promotion research and activities. Given our conceptual framework, we discuss the determinants according to the socio-ecological level they can be classified in.
Age does not play a decisive role in defining sexual health in our study population. Both young and adult respondents define sexual health in a rather balanced way identifying aspects of general well-being, a respectful approach of sexual relationships and sexuality, a safe and pleasurable sex life, family planning and fertility and access to information and care. Yet pathways to search for sexual health information differ. Youth indicate their direct environment as primary sexual health source while the health sector, media - preferably internet- and educational institutions share an equal important second place. In identifying determinants, respondents attribute more importance to a safe and satisfying sex life than adults and indicate determinants preferably in the individual and intimate interpersonal level.
“A human being is a human being, whether you’re a man or a woman” (Maiah, 34, female Kurdish asylum seeker)
Gender Although it is often assumed that gender imbalances induced by beliefs, practices and norms of the countries of origin of our respondents might have a negative effect on their sexual health, our results rather confirm earlier findings  that there are no ground-breaking gender differences regarding sexual health definition and determinants in our population. When defining sexual health, both male and female respondents emphasized that the most important element was to be physically and mentally well. In addition to being well, one had to feel well about sexuality both personally as within a respectful relationship where trust and mutual respect were named as essential to it, which is in line with literature [39–42]. However, a safe and satisfying sex life was for both genders an equally important aspect. Within their descriptions of what this should entail, we could not state that men indicated more stimulus-based factors and women more cognition-based factors -as emotions, the broader quality of a relationship, dyadic conflict, personalized external events and social context factors- which is posited in literature emphasizing differences between gender [39, 43–47]. Respondents did not attribute major differences in sexual maturity criteria either. In addition, for both females and males, fertility, family planning and access to information and care were of less importance. As for the sources of sexual health information, the health sector was indicated as the readiest SHI source for both women and men.
The only differences we could find between genders were the explored pathways in search for SHI. Compared to their male counterparts, women and girls tend to address people in their direct environment and especially friends much more. They also prefer media –especially books- more than men who then prefer internet if they indicate media as source of sexual health information. Women also indicated institutions more, preferably educational institutions but also religious ones. Thus, future sexual health promotion activities towards migrants descending from these origins can be gender inclusive when it concerns content. Only the channels through which the messages are conveyed could be diversified to maximize the possibilities of getting the message across.
Cultural beliefs and norms that have been equally incorporated by women and men seem to influence their sexual health frame of reference decisively.
“In Iran they say you get blind if you masturbate, here they say it’s good for your health” (Bârân, 26, female Iranian Refugee)
When respondents described criteria for sexual maturity, all stressed the importance of a balanced mental, physical and social development as the most decisive element for both genders. Age and respectful approach were criteria for both girls and boys and were indicated by a third to a fourth of the respondents. Yet, we saw that country of origin clearly influences these findings. Somali and Afghan respondents tended to emphasize the physical development aspects and an earlier age of sexual maturity (girls 13–15, boys 15–17) more than the others. For them, issues related to sexual debut, fertility and family planning were rarely mentioned, while aspects of respectful approach were stressed. This tendency is consistent with their definition of sexual health whereby aspects of general well-being and a safe and satisfying sex life are mentioned as important aspects to all origins. However, respondents from Somalia, Iraq, Iran and Afghanistan stressed that this should happen within a steady relation (mostly marriage) where one feels respected, trusted and at ease. Yet, for CIS respondents and the Slovakian and Czech Roma ones, family planning seemed to be more of an issue in addition to a general well-being and a safe and satisfying sex life. This confirms literature stating that cultural norms, beliefs and attitudes bolster one’s self-esteem and self-efficacy, provide a coherent structure for interpreting life events  and are more decisive in sexual behaviour of these migrants than their separation from native communities . Yet, as the Belgian and Dutch asylum system enforces them in a dependent situation, their general beliefs and norms on sexual normalcy, on pleasurable sex, on risks to sexual dysfunction, on sexual performance as well as their ethical concerns about the function of sexuality, help-seeking and treatment; might be seriously challenged. All of this is known to create and perpetuate sexual difficulties [38, 49–54].
The attained education does not influence the perception of sexual maturity criteria, the importance of general well-being, a respectful approach or the personal health responsibility. Yet respondents with no or low education attainment levels tend to diversify their definition of sexual health less. Moreover, they particularly stress individual and intimate interpersonal sexual health determinants and consider family and friends as first sexual health information sources, additionally taking up on info spread by TV. Respondents with higher educational levels considered safety and satisfaction more as well as access to information and care. In addition, they mentioned more organizational and societal determinants and also preferred the health sector above all other sexual health information sources. This indicates that sexual health promotion activities could be more effective if they do not differentiate the content, but rather use other channels whereby migrants with lower education attainment seem to be more susceptible to gaining knowledge through experienced peers (informal help), while migrants with higher education attainment give more appraisal to persons who gained their knowledge and expertise through education and profession (formal help).
Health locus of control Our respondents demonstrated a predominant internal health locus of control as the majority was convinced that one is responsible for shaping and maintaining good sexual health. They were convinced this could be done by having a general healthy life style, using contraceptives, not having multiple sex partners, being informed on risks and prevention strategies and seeing a doctor when necessary. This is in line with earlier findings on internal health locus of control and sexual health [55–57]. Yet, most of them felt that this personal attitude was hugely challenged by the structural dependent situation they were living in. This situation is induced by the organization of the Belgian and Dutch asylum reception system and migration law, the impact of which we will discuss when addressing determinants at the organizational and societal level.
“I have no hope for the future. I live in a reception centre without any contact with other people. I have no money, no work and no contact with girls.” (Zoran, 23, male Kurdish asylum seeker)
Additionally, given the societal aspects of their restricted legal status which reduce possibilities to participate in Belgian and Dutch society , respondents are also structurally hampered tap their human and social capital. Literature has shown that having restricted social networks is not only bad for their mental health [58–60]; it also reduces the number and quality of channels they can address in search for sexual health prevention and promotion norms and strategies [61–63]. Our respondents, and especially the young as well as the female respondents, indicated that their direct environment, -preferably friends, parents and siblings-, were one of the first sexual health sources to consider. This confirms earlier literature stating that adolescents’ sexual behaviour is strongly influenced by peers [64, 65] and parents . Given these pathways, it is to be advised that refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands are empowered to strengthen social networks and are facilitated to take up an active parental or peer educative role in order to enhance the exchange of transferable knowledge skills through social learning and the creation of social support.
Organizational and societal level
Although 80% of the respondents reported to be practicing religion, only very rarely religion was mentioned as a determinant and in the analysis no links could be found either.
“Men are very proud if they speak about sex with their friends and it is a declaration of their sex excellence; but for women it is embarrassing to talk about sex. And I don’t think that the religion has an effect here.” (Farrah, 34, female Iraqi asylum seeker)
This questions the often suggested intervention to set up health promotion campaigns through religious institutions and by religious key people. In our, mostly highly educated, group of respondents it seemed that other institutional and public channels are preferable to address, as there is media, educational bodies and the health sector. Our findings confirm that in addition to traditional channels as TV, radio, books, magazines; it is wise to invest in social media as channels for culturally competent sexual health promotion activities emphasizing a positive, yet critical and balanced approach to sexual health and sexuality, especially when targeting youth [49, 66]. Educational bodies as schools and universities were indicated as facilitating sources for sexual health information rather than primary sources. This has to be taken in consideration in school programmes for minors since the right to education in Belgium and the Netherlands is restricted to the age of 18 for asylum seekers and undocumented migrants. For adults, this could be addressed through the language and societal courses that are often considered as compulsory to a potential prolonged stay in the host country. Yet, our findings confirm that these educational programs better not stem from one cognitive behavioural model solely but should take factors at all socio-ecological level into account . Given the preference for the health sector as primary sexual health source in all ages and genders and especially in more educated persons, and the induced external health locus of control putting more dependence on powerful others as health practitioners ; it needs to be emphasized that health workers should be strongly encouraged and trained to play a leading role in culturally competent sexual health promotion activities towards this population.
Finally, although the respondents demonstrated a predominantly internal health locus of control, most of them emphasized that this personal attitude is challenged, given the structural dependent situation enforced upon them by the current organization of the Belgian and Dutch asylum reception system and migration law.
“During this long period refugees are under constant fear, anxiety, stress and other mental disorder. They see no future and end up into drug abuse, frustration, sleeplessness and change of behaviour” (Keynaan, 36, male Somali asylum seeker)
They indicated that the asylum system and its procedures brought about stress, sadness and frustration, which they perceive as negatively impacting their sexual health. Moreover, the asylum system also creates barriers to being sexually active. Due to infrastructural limitations, the privacy for couples and families can physically nor emotionally be guaranteed, and both genders are either forced to live together or on the contrary separated from each other, irrespective of what residents would prefer as housing rules. Furthermore, in a lot of reception facilities there are strict rules on receiving guests. This all adds up to unavailability of intimacy and sex opportunities which are perceived as negative factors. Also in other domains of life as seeing a doctor, cooking, managing administration, participation in social activities outside the facilities, work and others; asylum seekers are taken care off and room for autonomy, own initiative or responsibility is heavily reduced. These social, political and practical challenges linked to the Belgian and Dutch asylum reception system dependency force migrants to have a more external passive health locus of control, reduced autonomy, low self-esteem, heightened stress and sexual unavailability. According to literature, these aspects are known to create sexual difficulties in both genders [39–42, 68–70] and may also lead to poor lifestyle, less adequate use of contraceptive methods, lower adherence and service utilisation and higher risk behaviour and susceptibility to ill-health [55–57, 71–73]. It is thus to be advised that the Belgian and Dutch asylum reception sector can dispose of organizational policies that promote sexual health rather than restricting it by enhancing the individual capacities and skills of residents thereby facilitating their proper mastering of health and inducing good sexual health at the long run.