Pathways for sexual health promotion among Indigenous boys and men: stakeholder perspectives

Abstract

The sexual health of Indigenous Peoples in Canada has been identified as an important community and public health concern; however, there is a lack of research on the sexual health needs of Indigenous boys and men. This article shares results from interviews conducted with six stakeholders to explore pathways for sexual health promotion and considers the impacts of colonialism and other socio-political contextual factors on Indigenous boys’ and men’s sexual health. The study employed thematic analysis, and the findings indicate the following three pathways for sexual health promotion of Indigenous boys and men: (1) developing healthy relationships and highlighting role models, (2) providing access to comprehensive sexual health information, and (3) fostering open communication among Indigenous boys and men. Sexual health promotion with Indigenous boys and men in Atlantic Canada should include addressing the impacts of colonization and their unique socio-cultural contexts.

Introduction

In this article, Indigenous is used to broadly refer to the Original Peoples of a particular territory. For context, this research is located in what is now known as Canada, and thus the term Indigenous in this study collectively refers to three distinct sovereign Peoples who are Indigenous to this territory: First Nations, Métis, and Inuit. First Nations peoples are those with ancestral ties to Turtle Island, known colonially as North America. While often referred to collectively, First Nations peoples belong to many Nations with distinct cultures, histories, traditions, and language groups. Métis peoples are descendants from a specific generation of mixed First Nations and European ancestry sharing distinct language and nationhood. Inuit peoples are the traditional peoples of the Arctic regions, which within Canada refers to those with ancestral ties to the territory of Inuit Nunangat (Inuit land, water, and ice in what is now known as the Northwest Territories, Nunavut, Quebec, and Labrador).

From an Indigenous perspective, sexual health involves the holistic connections between the body, mind, and spirit for balanced wellbeing (First Nations Centre/National Aboriginal Health Organization, 2010). The area of study surrounding Indigenous Peoples’ sexual health, particularly Indigenous boys’ and men’s sexual health, sexualities, and masculinities, is growing (Hokowhitu, 2012; Innes & Anderson, 2015; McKegney, 2014; Vinyeta et al., 2016). Despite this growth, there is still a dearth of literature that examines holistic approaches to sexual health promotion for Indigenous boys and men. Specifically, there is limited research that centres the unique needs and realities of Indigenous boys and men related to their sexual health. The aim of this article is to explore the perspectives of community stakeholders regarding pathways for sexual health promotion among Indigenous boys and men and elicit recommendations to implement such pathways. This focus on stakeholders is one part of our broader four-part study that included community consultations (Doria et al., 2019), a rapid review of literature exploring the sexual health of Indigenous boys and men in Canada (Hackett et al., 2021), and key informant interviews with Indigenous men who participated in community-based programming through one of our community partners (manuscript forthcoming). We focus on Indigenous health literature broadly, and more specifically sexual health literature, and have mainly drawn on Canadian studies and resources.

Indigenous sexual health

Although no single definition of Indigenous sexual health exists, across Canada there are valuable models and specific factors we draw on to conceptualize our understanding of Indigenous sexual health. The First Nations Health Authority (FNHA) in British Columbia has developed a holistic sexual wellbeing model for use within their wellness programming. The strengths-based model is grounded in “traditional knowledge and ways of being in regard to healthy sexuality” (FNHA, n.d., para. 1). Strength-based approaches “focus on the capacity to achieve wellness despite adversity” (George et al., 2019, p. 164). The foundational values for their sexual wellbeing model are (1) protecting communities, including from communicable diseases; (2) developing healthy relationships with self and others; (3) exploring Indigenous identities in relation to sexuality; and (4) adulthood and rites of passage honouring the transitions that bodies go through in puberty (FNHA, n.d.). Furthermore, the Ontario Federation of Indigenous Friendship Centres (OFIFC, 2016) specifically acknowledge that the current sexual health of Indigenous Peoples is shaped by complex social conditions, such as family violence, early parenthood, school dropout, racism, sexism, and homophobia. We draw on their exploration of key factors influencing the sexual health of Indigenous Peoples in developing our working understanding for this article and consider the impact of these social condition in our analysis of this study.

The currently available literature insufficiently explores Indigenous boys’ and men’s sexual health in culturally grounded, multi-dimensional ways. Previous studies in Canada have compared the sexual health of Indigenous Peoples to the non-Indigenous population and concluded that Indigenous populations experience comparatively poorer sexual health outcomes (Duncan et al., 2011; Yee et al., 2011). For example, many Indigenous communities in Canada experience disproportionately higher rates of HIV and other sexually transmitted and blood-borne infections (STBBIs) (Duncan et al., 2011; Yee et al., 2011). Other studies reveal poor sexual health outcomes and sexual health inequities experienced by Indigenous Peoples. Devries and Free (2011) found that Indigenous youth are more likely than other Canadian youth to report inconsistent condom use and sexualized violence. In addition, in comparison with non-Indigenous populations in Canada, Indigenous communities have higher rates of teen parenthood, which is a phenomenon that is often associated with lower educational attainment and socio-economic status due to the legacy of colonization (Ball, 2010; Garner et al., 2013, OFIFC, 2016). Given that research to date exploring the sexual health and wellness of Indigenous Peoples has focused primarily on the sexual health of Indigenous girls and women (Bingham et al., 2014; Grace, 2003; Lys & Reading, 2012), there is a lack of research exploring the sexual health of Indigenous boys and men.

The impact of colonialism on Indigenous Peoples’ sexual health

Prior to colonization, teachings and traditions related to sexuality were not seen as shameful or taboo in First Nations communities. Children were openly taught about sexual and reproductive health and their bodies; however, “loss of traditional knowledge, language, land, ceremonies and cultural practices, including gender roles and birthing ceremonies, has influenced sexual health and sexuality for First Nations” (First Nations Centre/National Aboriginal Health Organization, 2010, p. 2). The historical and contemporary impacts of colonialism, including the Indian Residential School (IRS) system, land dispossession, forced cultural assimilation, and racism in the health care system, create and maintain Indigenous Peoples’ health inequities (Kirmayer et al., 2011). It is well documented in both narrative testimony and literature that legacies of physical, emotional, spiritual, and sexual abuse that occurred within IRS still impact many Indigenous Peoples today through intergenerational trauma (Aguiar & Halseth, 2015; Bombay et al., 2011; Reading, 2015; Truth and Reconciliation Commission of Canada, 2015). Intergenerational trauma is defined as a process and form of psychological trauma transmitted within families and communities and can be “transmitted through attachment relationships where the parent has experienced relational trauma and have significant impacts upon individuals across the lifespan, including predisposition to further trauma” (Isobel et al., 2020, p. 1). Less is known about the implications of colonial trauma across the lifespan for Indigenous boys and men. Although there is a growing body of literature in Canada that is focused on the intergenerational effects of colonial trauma, few studies focus on the mental health outcomes for Indigenous boys and men specifically (Reeves & Stewart, 2017).

Indigenous boys and men have experienced lasting negative effects on their health and wellbeing, including their sexual health and gender roles (Robinson, 2020; Truth and Reconciliation Commission of Canada, 2015). The impact of the IRS system on Indigenous boys’ and men’s concepts of masculinity is especially poignant as the system was “integral to processes of imposing racialized gender hierarchies among diverse Indigenous communities” (Hunt, 2015, p. 106). The IRS has disrupted traditional teachings of gender. For instance, a qualitative study by Getty (2013) revealed for Mi’kmaq (First Nations peoples of the Northeastern Woodlands of the Atlantic Provinces and Quebec, Canada, and Maine, United States) men in Elsipogtog First Nation that their traditional masculinity practices were affected by colonization, unsettling their roles and egalitarian relationships. Another qualitative study examining the health and wellbeing of First Nations men revealed that the processes of colonization disrupted men’s roles as protectors and providers, and impeded their attempts to be self-supporting (Mussell, 2005). In addition to disruption of gender identity, research indicates that sexual health is linked to the Historical Loss caused by colonialism. Anastario and colleagues (2013) in their work examine the linkages between sexual risk behaviours and Historical Loss symptoms in American Indian men in Northeastern Montana. Historical Loss is a type of intergenerational trauma, and for American Indians, “Historical Loss may include experiencing the loss of land, language, traditional spiritual ways, and other culturally significant events that are part of the cognitive process, and where perceptions of these losses are linked with psychological symptoms” (Anastario et al., 2013, p. 894). Their study revealed that Historical Loss symptoms were associated with sexual risk-taking behaviours (Anastario et al., 2013).

As part of our broader project, our research team conducted a rapid review exploring the scope of the literature regarding psychosocial dimensions of Indigenous boys’ and men’s sexual health in Canada specifically (Hackett et al., 2021). We found that boys’ and men’s sexual health is influenced by colonial disruption of family bonds, introduction of Euro-Christian conceptualizations of masculinity, and lack of access to sexual health resources (Hackett et al., 2021). These findings suggest that further research is needed to identify pathways for sexual health promotion that are relevant to Indigenous boys and men in Canada (Hackett et al., 2021).

Methods

Understanding the unique determinants of health of any community requires listening to the insights of first-person perspectives (Jamieson et al., 2012); community stakeholders provide one such insight. Stakeholders can provide in-depth experiences and knowledge-based perspectives on under-researched topics, provide useful insights, and are often in change-making positions (Braun et al., 2009; Terry et al., 2012). Previous Indigenous health research has used the perspectives of stakeholders to explore a variety of topics, including health performance–measuring systems and maternal–infant health (Kildea et al., 2018; Smylie et al., 2006). There is a call for researchers who are working towards identifying gaps in current Indigenous health research frameworks to prioritize the involvement of Indigenous community leaders as well as stakeholders (Ninomiya & Pollock, 2017). Therefore, stakeholders working within Indigenous sexual health are an appropriate group to call in to our exploration of the sexual health needs of Indigenous boys and men.

Research relationships

Relationships are an imperative precursor for ethical research with Indigenous communities (Bull, 2010). The relationships that bring strength to this study are those between the Sexual Health and Gender Research Lab at Dalhousie University, the Mi’kmaw (adjective, of the Nation of the Mik’maq people) Native Friendship Centre, and Healing Our Nations. All three partners all located in Mi’kma’ki (unceded land of the Mi’kmaq with which the Mi’kmaq have ancestral and ongoing relationships), specifically Kjipuktuk (Halifax) and Punamu’kwati’jk (Dartmouth) in Nova Scotia. The Sexual Health and Gender Research Lab at Dalhousie University is led by settler scholar Dr Matthew Numer, and along with associated students, they study LGBTQ+ (lesbian, gay, bisexual, transgender, queer and questioning, plus others) health, sexualized violence, Indigenous boys’ and men’s health, and e-learning. The Mi’kmaw Native Friendship Centre, which opened in 1972, is one of 119 Friendship Centres across Canada (Mi’kmaw Native Friendship Centre, 2020). The Mi’kmaw Native Friendship Centre is a non-profit, Indigenous-governed organization that offers 22 programmes aiming to improve the lives of urban Indigenous Peoples and to respond to community needs. In 2000, Healing Our Nations emerged from the Nova Scotia and Atlantic Mi’kmaq AIDS Task Force. Grounded in respect for Indigenous ways of life, Healing Our Nations focuses on First Nations HIV education and prevention education. More broadly, the goal of Healing Our Nations is to “help First Nation people rediscover their pride, traditions, and spirituality in an attempt to improve child development and eliminate family violence, substance abuse, depression, and suicide” (Healing Our Nations, n.d., para. 2). Cultivated over the past 3 years, the relationship between these three partners has resulted in numerous collaborations. Partners from Dalhousie University, the Mi’kmaw Native Friendship Centre, and Healing Our Nations worked collaboratively on all aspects of this study, including informing the research questions, recruitment, data collection, and the dissemination of findings. All partners have also worked in together in development of this article and are co-authors.

Ethical approval for the broader project in its entirety was obtained from both the Dalhousie University Research Ethics Board and the Mi’kmaw Ethics Watch, which is the regional Indigenous ethical review board. The broader project included community consultations through the Atlantic First Nations Health Conference, a rapid review of literature exploring the sexual health of Indigenous boys and men in Canada, and key informant interviews with Indigenous men who participated in cultural programming through one of our community partners.

Methodological stance: Two-Eyed Seeing

The development of the broader project was based on community-based research methods guided by the principles of Two-Eyed Seeing (Bartlett et al., 2012) and community-driven participatory action research. These principles have ensured that Indigenous community members were active partners in all stages of the research process: identifying the need for the research, identifying research objectives and questions, collecting and analysing data, and reporting and applying the results.

Two-Eyed Seeing as a guiding principle was first described by Mi’kmaq Elders Albert and Murdena Marshall. In Elder Albert’s words, it means,

To see from one eye with the strengths of Indigenous ways of knowing, and to see from the other eye with the strengths of Western ways of knowing, and to use both of these eyes together for the benefit of all. (Bartlett et al., 2012, p. 335)

Scholars are increasingly relying on the guiding principle of Two-Eyed Seeing to guide their collaborative research that draws on Indigenous ways of knowing and Western ways of knowing together in their studies (Latimer et al., 2020; Wright et al., 2019). We too draw on Two-Eyed Seeing to bring together multiple ways of knowing and strengthen our collaborative work.

Data collection and analysis

This study used a qualitative research approach, focused on conversational methods (Kovach, 2010). Conversational methods such as semi-structured interviews are congruent with Indigenous ways of knowledge sharing because they provide the opportunity to share stories, provide context, and convey lived realities. Furthermore, conversational methods are important for research that brings together Indigenous and non-Indigenous researchers because “story, as both form and method, crosses cultural divides” to share common understandings of phenomena (Kovach, 2010, p. 96). One-on-one semi-structured interviews were conducted by research team members Nicole Doria, Jenny Rand, and Matthew Numer with six community stakeholders across Canada who work with Indigenous boys and men in the field of sexual health. At the time of the interviews, five stakeholders were working in the Atlantic Provinces of Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador, and one stakeholder was working in the Northwest Territories. All stakeholders spoke to their experiences specifically working with Indigenous boys and men in their regions and across Canada.

Purposive sampling was used for participant recruitment, as partners at Healing Our Nations and the Mi’kmaw Native Friendship Centre recommended potential interview participants. These recommendations resulted in six interviews with stakeholders who worked with Indigenous boys and men in sexual health. Stakeholders were contacted by email and all respondents were interviewed. Stakeholder Indigenous identity was not required for inclusion in this project; as such, stakeholders who were interviewed were not asked to self-identify. The stakeholders who participated in interviews held a variety of roles including programme manager, community leader, facilitator, educator, and director, all of which place them in positions to have valuable insights into the needs of sexual health promotion programming and intervention for Indigenous boys and men. Given the relatively small pool of professionals working in this area, further demographic details are not provided to ensure privacy and confidentiality. Prior to the interview, an informed consent form was provided to and signed by stakeholders. Interviews took place in person (4) and over the phone (2), using a semi-structured interview guide. Each interview ranged from 60 to 90 min in duration and was audio-recorded and transcribed verbatim.

Interview data were analysed using thematic analysis (Braun & Clarke, 2006). Two members of the research team (J.S., L.H.) familiarized themselves with the interview transcripts and generated initial codes and themes. Coding and preliminary themes were compared and discussed by the broader research team (M.B., N.D., J.S., L.H., M.N.), and final themes were identified. Partners from Healing Our Nations and the Mi’kmaw Native Friendship Centre reviewed the final analyses and approved them, agreeing that they were consistent with their perspectives. Through the use of a qualitative methodology, the researchers were able to elicit the complex experiences of stakeholders in the area of Indigenous boys’ and men’s sexual health, and gain insight into the needs of Indigenous boys and men in this area.

Findings and discussion

The stakeholders interviewed in our study described the sexual health of Indigenous boys and men as being influenced by social, political, and cultural factors. All of the stakeholders discussed the lasting negative impacts of colonial institutions, such as the IRS system and hegemonic masculinity in relation to the sexual health of Indigenous boys and men. These factors resulted in normalizing physical and sexual violence among Indigenous peoples, stigmatizing sexual health, and weakening the bonds between family, communities, and culture. Hegemonic masculinity is a term that describes “an idealized notion of masculinity within a particular cultural context and time period” (Reeves & Stewart, 2017, p. 32). In North America, Euro-Western cultures dictate the dominant notions of masculinity through imperialism and Judeo-Christian influences, among other Euro-Western systems and messaging (Connell, 1993). Themes included in the concept of hegemonic masculinity are “independence, self-reliance, stoicism, heteronormativity, strength, invulnerability, risk taking, financial success and power, and high desire for sex” (Reeves & Stewart, 2017, p. 32).

The link between Indigenous peoples’ health outcomes and the IRS system is well established, and several studies have specifically noted adverse sexual health outcomes (Healey, 2014a; Wilk et al., 2017). Between 1884 and 1996, Indigenous children were apprehended and institutionalized in IRSs with the goal of assimilating them into Euro-Christian culture (Union of Ontario Indians, 2013). The forced removal of children from their communities severed relationships between children and their Elders that were integral to the transference of knowledge and preservation of Indigenous cultures and traditions (Healey, 2014a; OFIFC, 2016). Children were also prevented from being nurtured by their families and communities, leading to a lack of learning around positive sexual health practices (Hackett et al., 2021). The stakeholders in this study described the continued ways in which the IRS impacts boys’ and men’s sexual health today, by impeding open communication and depriving them of role models that can exemplify positive sexual health.

In exploring these issues, stakeholders identified three pathways to promote the sexual health of Indigenous boys and men: (1) developing healthy relationships and highlighting role models, (2) providing access to comprehensive sexual health information, and (3) fostering open communication.

Developing healthy relationships and highlighting role models

All stakeholders discussed how the relationships that Indigenous boys and men have with themselves, others, communities, and cultures influence their sexual health. As one stakeholder explained, “sexual health involves. . . not only the prevention of disease or negative outcomes, but also fostering healthy relationships with self, . . . others, and community, and making the best choices for oneself” (P6). Given the negative effects of colonial policies, however, all stakeholders noted that unhealthy relationships and poor sexual health are common among many Indigenous families. While discussing the negative impact on relationships due to intergenerational trauma, one stakeholder remarked, “because of all the intergenerational stuff [trauma], . . . I’ve never actually seen a man be healthy in a relationship” (P4). Stakeholders agreed that a lack of healthy relationships has resulted in lasting impacts on the sexual wellbeing of Indigenous boys and men.

Intergenerational trauma includes physical, emotional, cultural, and psychosocial trauma. This has introduced cycles of violence in Indigenous families that negatively impact sexual health and have contributed to fracturing relationships in many Indigenous families. As a result, there is a lack positive role models informing healthy relationships and positive sexual health. One stakeholder described this in the context of abuse: “whether it’s physical or verbal abuse, a lot of them don’t get healthy relationship stuff . . . so of course because they don’t get healthy relationship training, they have unhealthy relationships” (P3). A lack of modelling results in a cycle where children do not have positive role models and, in turn, struggle to fill that role for their own children. Many stakeholders commented that positive role models are one of the most effective ways to foster healthy sexual behaviours and relationships. One stakeholder spoke to the power role models can have, saying,

The role model, I think is probably more powerful than anything you know, especially for these guys. They’re more likely to be moved and continually moved by somebody that they can relate to who’s doing [expletive] that they would like to be doing and having successes that they would like to have than any number of rehabilitative programming or seminars. (P4)

Stakeholders noted that role models have the ability to help youth to reframe hypermasculine ideals and negative coping strategies that have often been adopted to manage trauma. The same stakeholder commented on the ability for role models to normalize vulnerability:

The idea came up of men in communities teaching younger men about how to be gentle and the value of being gentle. Having that as part of a positive male character, it’s not all just swashbuckling and slaying animals and stuff. (P4)

Stakeholders’ ideas surrounding the importance of role modelling to demonstrate healthy relationships illustrate a pathway grounded in Indigenous ways of knowing. Healthy relationship role modelling is highlighted in an Inuit community–based research project examining what is needed for community-based sexual health promotion (Rand, 2016). It is emphasized as an important approach for Inuit community sexual health promotion and is noted to be in line with Inuit ways of learning through observation and practice (Rand, 2016).

Another stakeholder explained the difficulty for Indigenous boys and men to find positive role models: “it’s a really hard process, like how do we learn? Where do we find role models?” (P1). The stakeholders in our study emphasized that young men need exposure to “people that are actively promoting a better community or a better sense of community, . . . because it would allow the young men to see these individuals in more of a positive light” (P5). Stakeholders emphasized the crucial role that positive role models can play in fostering positive sexual health and relationships among Indigenous boys and men. Moreover, these results demonstrate a need to create opportunities for boys and men to engage with positive role models as part of a broader narrative exploring the unique implications of colonization on the health and wellness of Indigenous boys and men.

Due to a lack of parental modelling resultant from the abuse at IRS, survivors had no alternative but to replicate harmful practices with their own children (OFIFC, 2016; Reeves & Stewart, 2015). Notions of healthy sexuality within Indigenous communities were taught through the guidance of parents, family, Elders, and community (OFIFC, 2016). The stakeholders in this study emphasized the importance of highlighting positive role models of healthy relationships as a pathway to promote Indigenous boys’ and men’s sexual health. These findings are consistent with previous literature that identifies a need to nurture relationships between Elders and Inuit youth, and to support parent–child communication about sexual health (Rand, 2016). Fostering positive relationships between father figures and children has also been identified as necessary to improve the sexual health of men today and for future generations (Ball, 2010; OFIFC, 2016). In addition, building healthy relationships plays a vital role in healing processes for Indigenous boys and men (Waldram, 2008).

Providing access to comprehensive sexual health information

The majority of stakeholders reported that current access to sexual health information is limited, which is often attributed to colonial policies and Western religions. Institutions such as the IRS system have stifled discussions of sexual health and introduced trauma surrounding sexual health and sexuality. The narratives of abuse through the IRS were fundamentally intertwined with religion, as many of the IRSs were Christian institutions. This narrative has been further complicated by the fact that within some Indigenous communities people practise Christianity, which several stakeholders explained challenged community members’ abilities to talk about sexual health. As one stakeholder said, “we have educators. . . you have your generic sex ed, but the mentality is very Christianized from my community” (P2). This stakeholder, and others, implied that a Christianized mentality has further rendered sex and sexuality as taboo subjects that are not to be discussed openly or in detail. As a result, the scope of sexual health information for Indigenous boys and men is narrow.

The argument by stakeholders that access to sexual health information has been complicated by Christian views of sexuality is rooted in the loss of traditional teachings of sex, sexuality, and gender. Within the IRS system, students were taught religious rhetoric that promoted male dominance and stigmatized sex (Innes & Anderson, 2015). IRS systematically suppressed conversations pertaining to sexual health and prevented the dissemination of information regarding sexual organs and their functioning (Henderson et al., 2018). These experiences have resulted in a cycle of misinformation leading to poorer sexual health outcomes still prevalent today. Stakeholders in this study noted that ending this cycle requires accurate information about sexual health to be made widely available to Indigenous boys and men.

Many stakeholders explained that Indigenous youth and men alike are missing comprehensive information on sexual health. For example, they do not have a basic understanding of anatomy, physiology, and information about normal bodily and sexual functions. One stakeholder explained,

I’ve had questions [about] what’s normal as a man? We don’t know, like you know a forty-year-old man is asking me is it normal for me to have morning [erection]? Yah, it’s completely normal. . . . But . . . it’s not talked about. (P2)

In some communities, sexual health information related to STBBI and treatment is poorly understood. One stakeholder explained, some men believe that STBBIs only exist in urban areas and are not relevant to their communities:

There’s the idea on the smaller reserves that all of the things that could happen to you in the city don’t come back to the reserve. Like you know oh that’s basically [a city problem], you know they’ve got to worry about AIDS and STDs and drug stuff and all these things but we’re here. (P3)

As a result, this stakeholder believes many individuals underestimate the risk of STBBIs to their own sexual health. Stakeholders identified a need to provide accurate, comprehensive sexual health information. This information includes basic sexual function, STBBIs, and the nuances of sexual consent. Stakeholders, however, identified several challenges related to making such information accessible, including beliefs and practices about religiosity, masculinity, and social scripts.

Stakeholders told us that information regarding STBBIs is a key component of sexual health education. Previous research has demonstrated that some Elders and Inuit community leaders lack knowledge of the subject (Rand, 2016). A common misconception is that STBBIs, including HIV, do not exist in Indigenous communities (Rand, 2016). Attitudes of STBBIs, including that HIV is not a risk on-reserve, are reported to be due to the attitude that it is a white man’s disease or a city problem, given its associations with intravenous drug use as the main mode of transmission (The Thunder Bay District Health Unit, 2018). Stakeholders in this study similarly remarked that Indigenous boys and men inaccurately believe that STBBIs are only a concern for larger urban centres, rather than smaller communities or on reserves. Several studies have demonstrated that Indigenous populations report disproportionately higher rates of STBBIs than non-Indigenous Canadians (Duncan et al., 2011; Yee et al., 2011). As such, there is a need to ensure that accurate information regarding STBBIs is provided to Indigenous boys and men. This type of education will likely encourage the uptake of safer practices and reduce transmission of STBBIs.

The lack of comprehensive sexual health information goes beyond sexual health and STBBIs and is interconnected with sexual relationships, impacting understandings of what consent looks like in sexual relationships. The information pertaining to the misunderstandings of the nuances of sexual consent was specifically emphasized. Western hegemonic views of masculinity persist among Indigenous young people, influencing their perception of gender roles in relationships (Devries & Free, 2011). As a result, it is common for boys and men to have been deprived of access to information regarding sexual consent and related practices.

Stakeholders further explained that many Indigenous boys and men lack a clear understanding of the nuances of capacity to consent for sexual activities. Stakeholders commented on how context of consent exacerbated misunderstandings in sexual situations, particularly in relation to drugs and alcohol. For example,

We talk about consent and explaining that if you’re under the influence of alcohol or any narcotic or drug that you aren’t basically able to give consent. And how shocked that a lot of people are when you explain that. (P5)

The surprise people expressed when learning about consent was in part associated with the normalization of sexual activity and substance use. This issue is often compounded when gender is taken into account. Devries and colleagues (2009) examined substance use and sexual behaviour among Indigenous youth and reported that of the 380 Indigenous boys who indicated they were sexually active, 33.8% reported using substances the last time they had sexual intercourse. Furthermore, the Nova Scotia Student Drug Use Survey reported that among students who had had sex in the previous year, 32.1% had unplanned sex while using substances (Asbridge & Langille, 2103). The Asbridge and Langille study did not specifically identify Indigenous identity. The association between alcohol use and sexual decision-making with adolescents is an important consideration within teachings of consent and sexual health.

It is common for boys and men to have been deprived of access to proper information regarding sexual consent and related practices. Hegemonic masculinity was identified as a conditioned stereotypical masculine gender identity among Indigenous men in Canada. The stakeholders noted that men often learn that traits such as dominance, aggression, and even violence were rewarded. These perceptions of masculinity influence their sexual practices related to aggressive sexual behaviour and consent. In fact, one stakeholder explained that some Indigenous boys and men also view women who refuse sex as playing hard to get and are doing so to avoid being sexually promiscuous:

sometimes guys will go and have sex, you know, not consensual sex because that’s almost like what’s expected. They’re taught that no means maybe. And the girl just doesn’t want to say yes because she doesn’t want people to think she’s [sexually promiscuous]. So, she’s got to say no a couple of times first and then you’ve got to press it. It’s almost like that’s a culture that’s been taught. (P3)

Gender identities of Indigenous Peoples have been and continue to be impacted by colonization (Hunt, 2016; Robinson, 2020). Prior to colonization, the gender norms within Indigenous communities were varied, men were providers, and others were caretakers, which allowed for a wide range of gender expression (Reeves & Stewart, 2017). Indigenous boys were mentored by family to take on various roles. “These gender roles and gender norms were destabilized by the hegemonic masculine norms of the Euro-Western colonizer” (Reeves & Stewart, 2017, p. 33), which has resulted in Indigenous men being at increased risk of negative health and social outcomes due to contemporary gender norms (Reeves & Stewart, 2017).

Fostering open communication

All stakeholders reported that sexual health remains a taboo topic in many communities as one stated that “it’s not an area that comes up a lot” (P6). Another stakeholder said, “it [sexual health is] not talked about in my community” (P2). Stakeholders discussed that this can partially be attributed to parents being uncomfortable discussing sexual topics, which teaches young people shame and silence. One stakeholder reported, “I recently did a workshop that was how to talk to your kids about sex and one of the major issues were the comfort level of the adults as far as having those conversations” (P5). Stakeholders explored at length the need for open communication to improve the sexual health of Indigenous boys and men. One stakeholder stated, “I think within our communities we need to feel free enough to talk about most of this stuff” (P3). This discomfort in discussing sexual health was encountered by multiple stakeholders in their practices across geographic areas in Canada. Given this pervasive challenge, stakeholders viewed conversation as a crucial mechanism for improving sexual health, which helps to facilitate the development of healthy relationships. One stakeholder explained, “the more conversations you have, the more comfortable that the conversation will be right, but if you don’t have those conversations of course it’s going to be awkward” (P5). Frequent and open conversations were identified by stakeholders as a necessary mechanism to move past current discomforts that limit discussions about positive sexual health practices. The difficulty in openly discussing sexual health is noted in the work of Healey (2014b) and Rink et al. (2014) who work with Inuit communities in Canada and Greenland, respectively. Their conversations with Inuit parents in Nunavut and Greenland have revealed that although youth and parents want to discuss sexual health with their families, they find it difficult to do so.

Topics of sexual and gender diversity are equally as difficult to discuss. As Hunt (2016) suggests, “Aboriginal communities are still impacted by the imposition of colonial gender and sexual norms, as well as discrimination against gender-fluidity and homosexuality” (p.9). Understandings about Two-Spirit and other Indigenous Lesbian, Gay, Bisexual, Trans, Queer and Questioning (2SLGBTQ+) identities have been impacted by colonization through the IRS system, Christian imposition, and other assimilative policies and practices (Hunt, 2016). In particular, the loss of Indigenous languages has resulted in the loss and marginalization of the knowledge about Two-Spirit roles. This loss has made it difficult for Indigenous boys and men to communicate openly about gender and sexual diversity. One stakeholder described the discomfort “guys” display when gender and sexual orientation comes up:

. . .[with] a couple of guys [in our program] I could feel a little bit of bristle you know, it’s like as soon as you start talking about masculinity or asking questions about, that might even brush up against sexual orientation, you can just feel the vibe, it’s like oh no, where is this going to go? (P4)

This example highlights that discomfort surrounding diverse sexual and gender identities is prevalent and that sometimes boys and men react at the mere mention of these ideas.

Two stakeholders reported that there is stigma surrounding 2SLGBTQ+identities among Indigenous boys and men: “we’re still not caught up as far as same sex [relationships], like there’s a few that don’t give a [expletive] and you know but then a lot come from a lot of abuse because of that” (P3). Binary gender and heteronormativity instilled by the forcible conversion of Indigenous people to Christianity have resulted in some Indigenous communities holding homophobic attitudes (Robinson, 2020). Stakeholders suggested that improved communication about sexual health and exploring the complexities of 2SLGBTQ+ identities can begin to address some of the challenges experienced by Indigenous boys and men.

Stakeholders reported that limited communication has often silenced experiences of sexualized violence. Boys and men who have experienced sexualized violence often experience shame, self-loathing, and feeling silenced as a result of hegemonic masculine ideals. One stakeholder described the guilt and shame felt among men:

That’s what the law says, 98 percent of men who were abused become abusers right? So, they don’t talk about it. They carry the guilt and the shame because they can’t talk about it, no one’s able to say to them, like it wasn’t your fault, you know you were attacked by a predator. (P3)

In George and colleagues’ (2019) description of developing mental health services by and for Indigenous men in Kettle and Stony Point First Nation, they describe the struggles linked to abuse, shame, and trauma many Indigenous men experience and note that they at the same time are in search of a sense of belonging. This experience of trauma means there is a need to facilitate safer spaces for men to discuss victimization and to support survivors. One study suggested that traditional healing methods, such as cultural spiritual practices, may be seen as a good starting point (Reeves & Stewart, 2015). For instance, cultural healing methods including sweat lodge ceremonies, fire keeping, chopping wood, storytelling, drumming, fasting, smudging, and spending time on the land may support Indigenous boys and men’s sense of pride around their Indigeneity (Reeves & Stewart, 2017). The concept of “culture as treatment” as discussed by Reeves and Stewart (2017) is an important consideration for Indigenous boys’ and men’s sexual health, relationship building, learning, and community wellbeing (p. 53). Fostering healthy relationships through role modelling and practice for Indigenous boys and men can be a foundation for strong families and strong communities.

Conclusion

To our knowledge, this study was one of the first of its kind to explore stakeholder perspectives regarding pathways to improving the sexual health of Indigenous boys and men in Canada. It should be acknowledged that these six stakeholders work within certain regions of the country and their perspectives do not necessarily represent the insights of stakeholders working in other regions or countries. Our findings contribute to a growing body of literature on the sexual health promotion needs of Indigenous boys and men. Through qualitative interviews, we were able to explore the perspectives and complex experiences of stakeholders and gather recommendations for change. This study was grounded in the guiding principle of Two-Eyed Seeing, which created the space for both Indigenous ways of knowing and Western ways of knowing to come together to interpret the findings. Further research, as directed by Indigenous communities, is needed to strengthen recommendations for sexual health promotion with Indigenous boys and men across Canada—specifically, future research needs to recognize cultural and contextual diversity.

Stakeholders identified three key elements that must be addressed to improve the sexual health of Indigenous boys and men, which can be achieved by improving several socio-cultural dimensions. Specific pathways for sexual health promotion were identified, including promoting healthy relationships and highlighting role models, providing access to comprehensive sexual health information, and fostering open communication. It is expected that supporting these pathways will lead to improvements in sexual health outcomes among Indigenous boys and men. Interventions and health promotion activities that follow these recommendations may contribute to reduced rates of STBBIs, increased rates of sexual satisfaction, greater acceptance of diverse sexual identities, and greater capacity to participate in emotionally and physically safe relationships. Addressing these important socio-cultural dimensions of sexual health are critical for developing holistic and successful health promotion strategies with Indigenous boys and men.

Indigenous boys and men show strength and resilience against settler-colonial ideologies, structures, and praxis. Indigenous boys and men hold cultural values, knowledge, ways of doing, and ways of being that have persisted despite historical and contemporary colonialism. This strength holds the key to the (re)vitalization, (re)surgence, and (re)assertion of traditional views on sexuality, sexual and reproductive passages, and gender roles. Gathering knowledge and diverse perspectives from Indigenous boys and men, and those who work within the field of sexual health with Indigenous boys and men, will best reveal the pathways forward towards sexual wellness. Sexual health promotion with Indigenous boys and men must carefully consider the impacts of ongoing colonialism on sexual health and recognize Indigenous boys’ and men’s strength and work to (re)vitalize the knowledge that is already held.