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Sexual and Reproductive Health Initiative
Introduction
The 2021 Canadian federal budget recognized the need for nationally representative data on sexual and reproductive health to better inform and support programs and policies. There are currently no existing comprehensive data on a wide range of sexual and reproductive health indicators in Canada. The budget designated $7.6 million in funding over five years to Statistics Canada to develop and implement a national survey on sexual and reproductive health, with a focus on supporting women's health. Better information will help government and non-governmental organizations monitor, plan, implement and evaluate programs to improve the sexual and reproductive health of women and the efficiency of health services.
To ensure that the information collected remains relevant for the people and organizations that use it, Statistics Canada embarked on a broad engagement process with stakeholders and data users.
Consultative engagement objectives
A program with an emphasis on sexual and reproductive health was a new area of focus for Statistics Canada. To ensure the relevancy of the initiative, Statistics Canada conducted extensive engagement activities with diverse data users, stakeholders and interested parties across Canada to understand the type of information that should be available through the initiative and how the data could be used.
The objectives of the engagement activities were to
- understand specific sexual and reproductive health information needs
- ensure the relevancy of products and analyses
- enhance information sharing with stakeholders
- manage stakeholder expectations with respect to the scope of the initiative
- align with key government priorities, such as Statistics Canada's Disaggregated Data Action Plan and the federal 2SLGBTQI+ Action Plan.
Consultative engagement methods
Engagement activities with partners and stakeholders—which included federal, provincial and territorial governments; advocacy and civil society organizations; clinicians; administrators; medical and service delivery organizations; and academic researchers—took place between December 2021 and June 2022. Feedback was collected in three phases: virtual meetings with federal partners and non-governmental stakeholders; email submissions from partners, stakeholders, and data users and providers; and small-group virtual discussions with data users.
PHASE 1: Virtual meetings with partners and stakeholders
Statistics Canada began by engaging with federal partners and non-governmental stakeholders to inform them about the Sexual and Reproductive Health Initiative and to learn about their information needs for sexual and reproductive health. Virtual meetings were held in December 2021 to inform these stakeholders of broader engagement activities. These partners and stakeholders also helped identify additional people and groups, both governmental and non-governmental, for the second phase of engagement activities.
PHASE 2: Email submissions from partners, stakeholders, and data users and providers
The email submission phase was conducted between December 2021 and January 2022 to understand the information needs in relation to sexual and reproductive health from a broad perspective.
An open-ended engagement document was sent to partners and stakeholders. Partners and stakeholders were encouraged to forward the email to their networks and partners. Statistics Canada received feedback from about 40 different organizations. To gain an understanding of specific information needs and existing sources of information, participants were asked:
- which topics related to sexual and reproductive health they or their organization were interested in
- the population and geographies of interest
- why the information was relevant to their organization
- what existing sources of information their organization uses in their work on sexual and reproductive health.
PHASE 3: Virtual group discussions with data users
Email participants, their networks and partners were invited to participate in small-group discussions to identify priority topics for the Sexual and Reproductive Health Initiative. The discussions were held between March 2022 and June 2022.
The types of feedback sought from the discussions included:
- sexual and reproductive health information needs in relation to policy and research questions
- the policies and programs that the data and analyses could be used to inform
- the most important sexual and reproductive health information to capture for decision making
- barriers and challenges in regard to sexual and reproductive health equity.
Discussions were organized around the broad topics that came out of the virtual meetings and email submissions. The seven broad topics were:
- access to sexual and reproductive health resources and services
- reproductive decision making, contraception and abortion
- sexual behaviour
- sexual and reproductive health literacy
- sexually transmitted and blood-borne infections (STBBIs)
- female reproductive health over the life course, with a focus on menstruation, perimenopause and menopause
- sexual and reproductive health equity.
Statistics Canada also reached out to stakeholders to participate in sessions with a specific focus on Indigenous peoples, people with disabilities, racialized groups, 2SLGBTQI+ people, youth and seniors.
Findings of the consultative engagements
Overall, the engagement activities generated close to 400 information needs. The engagement activities were not meant to prioritize information needs but rather identify key information needs from a wide range of stakeholders and data users. The following key information needs, in no particular order, were identified.
Equity
Equity was a recurring theme across all engagement activities. As one participant stated, "Equity is a spectrum—what serves the majority of the population is not enough. Sexual and reproductive health is subjective to each person, community and culture." Partners and stakeholders indicated a need for information about sexual and reproductive health, including gender, age, socioeconomic status, disability, sexual orientation, education, Indigenous groups, racialized groups, immigrant status and geographical location, to better understand differences between and among groups.
Sexual and reproductive health awareness and literacy
There was agreement across the engagement activities that knowledge about sexual and reproductive health would help in the development of healthy attitudes and practices towards sexual and reproductive health and facilitate conversations with health care professionals, sexual partners and families about sexuality, gender identity, and other sexual and reproductive health needs.
Feedback indicated a need for information about access to comprehensive sexuality education. This included information on the breadth of sexual and reproductive health topics taught in schools (for example, the treatment, management and prevention of STBBIs; pregnancy prevention; and healthy sexuality). Participants also noted that culturally relevant sexuality education can help provide diverse perspectives and non-judgmental information. Participants raised concerns about misinformation around sexual and reproductive health and the sources people use to obtain information.
Menstruation, perimenopause and menopause
Participants stated that information is needed about physical, mental, social and economic experiences related to menstruation, perimenopause and menopause. It is important to understand the different reproductive stages and the impact on the daily lives of girls and women.
Information needs around menstruation included the age of menarche, as it marks the start of reproductive years. Participants stated that young women need better information before the start of menarche. This includes what is happening to their bodies, the types of products they can use, options for the management of menstrual pain, knowledge about pregnancy prevention and contraception, the prevention of sexually transmitted infections, and healthy sexuality.
Period poverty was seen as a contributing factor to reduced physical and social well-being of girls and women. Access to quality menstrual products was thought to be key to participating in school, work, home and leisure activities.
In relation to menopause, participants identified a need for information about the symptoms of perimenopause, the age of onset of menopause and whether the onset of menopause was natural or surgical. Menopause marks the end of the reproductive years and may be accompanied by physical, emotional and sexual changes. Understanding how perimenopausal and menopausal symptoms are experienced will help to understand the physical, mental, social and financial impact that menopause can have on women.
Menstruation to menopause: Symptoms and treatment
Participants mentioned that to identify health challenges related to sexual and reproductive health, women and health care providers need to be informed about what is normal and what is not normal in relation to symptoms of menstruation, perimenopause and menopause. Participants highlighted that too often women's symptoms of poor health are attributed to menstruation, perimenopause or menopause, and underlying conditions are not diagnosed. It was pointed out that women suffer through symptoms such as pain, excess bleeding, night sweats, memory loss and vaginal dryness rather than find a way to manage the symptoms or seek help from a health care provider.
Many participants stated that pain has been normalized across the lifespan for women and often prevents treatment. Women's experiences of both physical and emotional pain need to be validated and better treatment options offered.
Access to medical treatment rather than surgical intervention was another area of concern that participants pointed out. For example, many perimenopausal women may have hysterectomies rather than medical treatment such as the use of hormonal intrauterine devices because of costs. Surgical interventions are often pursued because of lack of coverage for medical treatment.
Maternal health, pregnancy and pregnancy outcomes
Participants spoke about the importance of data on maternal health, in particular maternal mortality and morbidity, pregnancy and childbirth, and access and barriers to receiving care during pregnancy. To track progress towards a more equitable health care system, it is important to have data available by Indigenous and racialized identity, care provider, geography, sexual orientation, and gender.
It was noted that data on alcohol and drug use during pregnancy were needed to understand what type of support and programs are required to help prevent negative maternal and fetal health outcomes, preterm birth, and fetal loss.
Nutrition during pregnancy was also of interest, in particular, to examine food insecurity. Knowing the prevalence and severity of food insecurity during pregnancy can help to inform policies and identify resources required for women who are pregnant. Participants also emphasized the importance of access to traditional foods for First Nations people, Métis and Inuit, as lack of access to these foods adds to Indigenous people's experiences of food insecurity and may negatively impact their spiritual, emotional, physical and mental well-being.
Participants also emphasized that services such as fertility treatments and in vitro fertilization can help same-sex couples, couples dealing with infertility and people wishing to have a child without a partner. Cost can be a barrier to accessing these services. Information on the need for, use of and accessibility of these services can help when making program and policy decisions.
Participants mentioned that people should be given the means to time their pregnancies and space their children to avoid unintended pregnancy and childbirth. Data are needed to determine rates of unintended pregnancy to help inform policy, program development and monitoring. Better information about unintended pregnancy and pregnancy outcomes will help to inform understanding of the relationship of these experiences to social, ecological and behavioural determinants of health. Information about the use and accessibility of care, medications and procedures for abortions, miscarriages, stillbirths and ectopic or tubal pregnancies will help to better understand issues related to accessing services, such as cost, wait times and distance travelled.
Contraception
Access and barriers to, and knowledge and use of, birth control were frequently mentioned by participants. Participants stated that access to contraception should be an informed choice. Women should be able to choose the type of contraception that is best suited to their needs rather than choosing no method or cheaper methods. Participants felt that there is a lack of information and knowledge about different types of contraception and the correct use of contraception. Some participants asserted that most policies focus on women's ability to breed the next generation rather than women having the choice of when and how to become pregnant.
Information needs around awareness, use and accessibility of emergency contraception were also identified.
Sexual behaviours
There were numerous information needs related to sexual behaviours. Sexual behaviours were regarded as a key indicator of sexual and reproductive health.
Participants noted that the age at first sexual experience and whether the experience was wanted or not can impact long-term sexual behaviour and well-being, as they can be associated with engaging in unprotected sex or being a victim of sexual abuse and can potentially lead to pregnancy. Participants discussed that information is needed on diverse sexual behaviours to better understand the prevalence of various sexual behaviours and the impact they have on sexual health outcomes.
Several participants expressed that while people with disabilities are sexual beings, their sexual and reproductive health needs have been disregarded. More information is needed to understand sexual and reproductive health care needs and barriers among people with disabilities to help support education, training, policies and programs.
Stress and anxiety around sexual performance were considered an important topic to many participants as they relate to sexual behaviour and sexual well-being. Additionally, information is needed to understand the impact of changes in sexual and reproductive health on mental health over the life cycle and the impact they may have on overall quality of life.
Participants emphasized that understanding healthy sexual functioning can reduce societal stigma and shame about sexual difficulties and empower people to seek treatment. It was further mentioned that data are needed on sexual satisfaction and pleasure, the ability to communicate about sexual needs and desires, and erectile dysfunction and other sexual difficulties. Additionally, information on the use of substances or medications for engaging in sexual activity can help to understand the impact they have on sexual behaviour and the enjoyment of sexual activity.
Participants explained that there is very little Canadian data on the prevalence of transactional sex (exchange of sex for money, favours or goods), the use of sexual assistive technology like vibrators for sexual activity, and the use of and increased access to pornography.
Participants highlighted that new trends may be emerging in the digital era. It is important to understand the impact of digital technology on sexual behaviours and relationships. Participants discussed the growth in using digital technology to find new sexual and romantic partners and initiate sexual experiences. Participants highlighted the need for more information about digital technologies in relation to sexual isolation, sexual satisfaction and sexual identity.
Aging and sexual and reproductive well-being
Participants expressed that aging should not be seen as a barrier to having a healthy sex life. Feedback included that there are many social stigmas attached to women as they age and are no longer fertile. However, this is a stage in life where there are fewer barriers for women; for example, there is no longer a need to worry about pregnancy.
Participants noted the need for information to help educate women as they age about the risks of sexually transmitted infections despite no longer requiring birth control to prevent pregnancies. Education should also include understanding symptoms such as vaginal dryness, hot flashes, sleep disturbances and changes to cognitive functioning and options for available treatments. Participants indicated that healthy sexual activity is still important as women age, and information is needed to promote their overall physical and emotional well-being.
Sexual violence
Experiences of sexual violence were an important issue for many participants. They stated that sexual violence can impact physical, mental and sexual health.
Participants expressed the need for information on unreported sexual assaults and on the availability of support services for sexual and reproductive health healing after experiencing sexual violence.
Participants also discussed the need for information about forced and coerced sterilization. Data are needed on the scope, severity and health outcomes among marginalized and vulnerable groups, for example, Indigenous women, people with disabilities and racialized groups.
Participants also identified a need for information on the health outcomes of women and girls who have experienced female genital mutilation/cutting (FGM/C). It was noted that this practice is recognized internationally as having physical and obstetric health complications, as well as psychological consequences. Determining whether the health outcomes of immigrant women and girls from FGM/C-practising countries differ from those of their counterparts from other countries can help inform health care providers of the unique health care needs of this group.
Chronic conditions and reproductive surgeries
Participants stated that information is needed to examine rates and determinants of health conditions affecting female sexual and reproductive health (e.g., pelvic organ prolapse, fibroids, endometriosis, polycystic ovary syndrome) and male sexual and reproductive health (e.g., ejaculation disorders, infertility). Other information needs included the prevalence of gynecological cancer; cancer treatments; and reproductive surgeries such as hysterectomy, removal of ovaries and vasectomy. Participants indicated that better information is needed on the impact these conditions and surgeries can have on overall sexual and reproductive health.
Infections
Participants indicated that STBBIs and human immunodeficiency virus (HIV) impact overall health, and the stigma and judgment of diagnoses can also impact one's social life. Data on STBBIs can support guidelines and can help to detect emerging trends of infections in the population. Participants further explained that information about access to testing, treatment and support for STBBIs, including preferred treatment and services such as self-test kits, can help identify and assess potential barriers and opportunities for new testing, treatment and prevention methods. A need for additional information on the use of pre-exposure prophylaxis and post-exposure prophylaxis for HIV prevention was also mentioned.
Information about urinary tract infections and yeast infections was also important to participants in understanding how these infections affect female reproductive health.
Access to and experiences with sexual and reproductive health services
Access to a family doctor whom patients are comfortable with was one of the most important information needs mentioned. People seeking services can be influenced by having access to care that is safe; tailored to their culture, religion and personal needs; and free from language barriers. Participants also mentioned the importance of having good experiences of health care, as high quality of care can help prevent negative health outcomes and increase the likelihood of seeking care in the future.
Participants indicated that there is very limited information about differences in access to sexual and reproductive health services. It is important to have information about who is accessing sexual and reproductive health services, the type of services being accessed, and the experiences of those accessing these services. For example, 2SLGBTQI+ individuals are considered underserved and require equitable sexual and reproductive health services that reflect their needs.
Information about experiences of discrimination in a health care setting was also of interest to participants, as they mentioned that this information can help to examine systemic and intersecting barriers and racism. Whether people have access to health care providers via alternate methods such as virtual clinics was also mentioned, as some participants pointed out that it may help to alleviate some barriers to sexual and reproductive health services.
Conclusion
The Sexual and Reproductive Health Initiative received support across all engagement activities. Participants agreed that data on sexual and reproductive health are important to support policies and programs at all levels of government, including across ministries, such as health and education ministries, and across advocacy organizations and support services. There are a number of existing and emerging data gaps related to sexual and reproductive health. While understanding health disparities is highly relevant to decision makers, the required data are often not available to support and implement evidence-based policies and programs.
Statistics Canada would like to thank all participants for their involvement in the engagement activities. Their valuable insights have helped guide the development of the Sexual and Reproductive Health Initiative, including the development of the questionnaire for the first pan-Canadian sexual and reproductive health survey conducted by Statistics Canada. This survey is scheduled to begin data collection in fall 2024.