BACKGROUND: Sexual and reproductive health and rights (SRHR) are a core determinant of health and constitute an important part of the transition from childhood to adulthood. The national SRHR-policy in Sweden strives towards health equity. In Sweden today, sexually transmitted infections (STIs) are common, which indicates a need for an increase in the practice of safer sex. Some groups are more vulnerable and more often experience unsafe sex, sex against their will and transactional sex. Further, in all these health outcome areas previous knowledge shows that young LGBTQI+ people, foreign-born youth and young people with insufficient economic resources display poorer sexual health. However, little is known about the conditions for health equity in the intersections within and between these social groups. Little is also known about whether and how resources for health equity are distributed from an intersectional perspective. AIM: The overall aim of this thesis is to explore the conditions for health equity in sexual and reproductive health and rights (SRHR) among young people in Sweden aged 16 to 29 by analysing the processes by which intersecting social determinants create vulnerabilities or resources in relation to SRHR. This overall aim is explored in four papers that cover six SRHR-related health outcomes. The three health outcome areas of unsafe sex, sex against one’s will, and transactional sex are viewed as vulnerabilities. The health outcome areas of safer sex, sexual health literacy and sex-life satisfaction are viewed as resources. METHODS: The empirical material employed in the studies presented in this thesis is drawn from the stratified and randomised national population-based survey ‘Sexuality and health among young people in Sweden’ also referred to as ‘UngKAB15’. A random sample of 29,950 young persons was drawn from the Total Population Register. A total of 7,755 respondents answered the survey, which gave a response rate of 26 percent. Descriptive (percentages) and analytical (regression models) statistical methods have been applied. RESULTS: Paper I shows that there is a need for both national and global policy and population-based surveys to be accompanied by an intersectional understanding of vulnerable positions in relation to SRHR. Otherwise, vulnerable groups may be excluded from SRHR interventions and thus left behind. Mapping the results using a stepwise, descriptive intersecting vulnerability scheme provides a visual understanding and indicates how gender intersects with sexual identity, transgender experience, perceived economy, being foreign-born and social welfare recipiency to produce vulnerable positions. In total, the scheme presents a visual understanding of intersecting vulnerable positions in relation to SRHR. Paper II shows an association between young people’s control over their life situation and their ability for safer sex. Control over one’s life can thus be defined as a resource for the ability to have safer sex. Gender alone cannot explain all the differences found in resources for safer sex, and an intersectional approach shows that gender and sexual identity are important determinants that can illuminate more or less resourceful positions. Paper III shows an association between on the one hand perceived insufficient knowledge from school-based sexuality education in five explored knowledge areas: the body, STIs, sexuality, relationships and gender equality, norms and LGBT-perspectives, and on the other hand higher odds of not being able to care for one’s sexual health. The highest excess risk of having insufficient knowledge and less resources was associated with belonging to a sexual minority. Paper IV show a univariate association between being satisfied with one's current sex life and good health, and this association remained and became slightly stronger in an adjusted model, indicating that young people may use sexlife satisfaction as a potential resource for good health. However, this resource is unequally distributed, since boys and non-binary youth are less satisfied with their current sex life than girls. CONCLUSION: This thesis contributes new knowledge in the form of an indepth understanding of how intersectionality constitutes a useful tool for exploring the conditions for health equity in SRHR among young people aged 16-29. The intersectional analysis helps to illuminate groups that have a more or less vulnerable or resourceful position in relation to each of the six health outcomes explored. The use of intersectional analysis has facilitated the identification of a range of complex patterns in the fields of vulnerability and resources and can thus produce improved knowledge on conditions for health equity in sexual and reproductive health (SRHR) among young people in Sweden. CONCLUSION AND IMPLICATIONS: When intersectionality is employed as an analytical tool, a complex pattern of vulnerabilities and resources in SRHRrelated health outcomes is revealed. This can be visualized using a descriptive intersecting vulnerability scheme. The intersectional perspective illuminates that gender is a determinant that needs to be analysed together with other social determinants in order to understand complexities in vulnerabilities and resources for health, since both vulnerabilities and resources are affected by the intersection between gender and sexual identity, transgender experience, economic resources, social welfare recipiency and being foreign-born. Overall, the findings indicate that global and national policy on gender equality in SRHR needs to be updated with both knowledge and tools that include intersectionality. FUTURE RESEARCH: Future research with a focus on intersectionality is needed to develop methods for handling small survey groups. Future studies can supplement categorizations based on the binary gender norm of women and men, girls and boys, and thus illuminate the wider diversity that exists in a population. More knowledge on diverse populations and the conditions for health equity can help to reach the global goal of Agenda 2030 “leaving no one behind”.
