Sexuality and Mental Health of Pakistani-Descent Adolescent Girls living in Canada: Perceptions and Recommendations

: In Canada, the demands of female immigrant adolescents in terms of sexual health are largely unmet and have grown signiﬁcantly in recent years. According to studies, racialized immigrant adolescents are less likely than non-immigrant adolescents to be knowledgeable about sexual and reproductive health and to use resources for sex education and related services. This difference seems to be related to socio-cultural and religious practices in Pakistani immigrant adolescents. This paper intends to explain the viewpoints of female adolescents of ﬁrst-or second-generation Pakistani descent who reside in Canada with regard to their development of sexuality and psychological well-being. Moreover, this paper also describes how female adolescents perceive the necessity to support their sexuality as they go through the adolescent stage. Individual interviews and timelines were created using qualitative interpretative descriptive design. We included 21 female adolescents of ﬁrst-or second-generation Pakistani ethnicity using a purposive sample. Data analysis was performed using a thematic analysis. The ﬁndings indicate that immigrant adolescent girls received conﬂicting messages about sexuality from their parents which impacted their psychological well-being. Additionally, survey participants noted that prejudice, exclusion from sex education classes, and a lack of sexual health information contributed to social isolation, health care avoidance, and poor mental health outcomes like melancholy and anxiety among adolescent girls. The absence of sexuality-related communication with parents and the scarcity of medical professionals who can relate to and address the needs and realities of immigrants may have an impact on the participants’ experiences. Female immigrant girls also spoke up on the need for open, honest, and stigma-free conversations as well as for the need to end the taboo around the subject of sexuality. This study used principles from both intersectionality and postmodern feminist theories to increase our understanding of the interplay between the experiences of developing sexuality and overall well-being in female immigrant adolescents of Pakistani descent. It is crucial to involve, listen to, and incorporate female adolescents’ voices when planning and implementing interventions to support healthy sexuality among immigrant adolescents.


Background
Important developmental tasks in adolescence include developing a sense of identity, building relationships, and acquiring the skills to cope with stress and life challenges [1,2].Globally, a significant number of adolescents are sexually active, and this proportion rises progressively from mid-to-late adolescence [3].In 2010, the International Planned Parenthood Federation stated that all adolescents should be able to explore, experience, and express their sexuality in healthy, positive, pleasurable, and safe ways.This is only possible when young people's sexual rights are understood, recognized, and guaranteed.However, female immigrant adolescents face unique challenges that prevent them from experiencing sexuality in a positive, healthy, and safe manner.This can have implications for their overall health and well-being.
The share of immigrant population migrating from Pakistan to Canada is growing rapidly, ranking Pakistanis among the largest foreign-born groups in Canada [4].In 2019, Pakistan was Canada's fifth-largest source of permanent residents, particularly in the youth population [5].Pakistani families' cultural value systems diverge from those of the West in many ways.Regarding dating, relationships, adolescent sexuality, gender roles and identity, and sexual orientation, Pakistani families hold a variety of cultural and religious viewpoints.These contrasts are especially noticeable within immigrant Pakistani households, where many of them uphold traditional, religious, and patriarchal norms and ideas around gender and sexuality.These important cultural differences often result in difficulties when adolescents are exposed to or socialized in western cultures [6].Research has shown that adolescents who are living in bicultural settings are more likely to engage in risky sexual behaviors due to the contradictory messages they received related to sexuality [7,8].Neglecting these challenges facing adolescents could seriously affect their sexual and reproductive health, but also their physical, social, and psychological wellbeing.Understanding the cultural environment in which sexuality occurs is essential for understanding sexuality.Discussions of female sexuality are frowned upon in South Asian culture, which operates under a patriarchal worldview [9].Taboos forbid behaviors because people feel that they would be too dangerous to engage in them.Most countries in South Asia are primarily patriarchal, where women are seen as inferiors and female sexuality is encouraged by rigid traditional social standards and gender role socialization [10].In the South Asian culture, women and girls typically refrain from acting on their sexual needs, expressing themselves as sexual beings, or allowing themselves to find pleasure in sexual activity.Women and girls are primarily taught by South Asian cultural values and societal standards that virginity, chastity, and purity are prerequisites for female marriage [11][12][13].Thus, South Asian women are reluctant to discuss sex-related issues, and this hesitation is frequently accompanied by feelings of humiliation, guilt, fear of being disparaged, and worry that they are stepping outside of social norms [14,15].Nowadays, although Pakistani women and girls have gained more independence, South Asian patriarchal socio-cultural practices continue to influence gender role expectations [16][17][18][19][20]. Various studies concerning female sexuality speak to the way patriarchal discourse combines with culture to create values, norms, and beliefs that influence female sexuality and the conceptualization and expression of sexual desire and behavior [21][22][23][24].These gender role expectations within Pakistani culture allow men greater sexual freedom than women.
A significant proportion of young people in Canada are immigrants with unique health needs in the context of physical, emotional, and social well-being [25].According to Statistics Canada (2017), almost one in every three newcomers was under 24 years of age and about half of these youth are from Asia [25].Despite the recognition of adolescence as an important developmental period, research on the experiences of Pakistani immigrant adolescents' sexuality and its potential impact on their well-being is scarce.
Adolescents struggle with a lack of readily available, youth-friendly sexual health services and limitations on the dissemination of pertinent information, particularly to unmarried females [26,27].Teenagers frequently lack the knowledge and skills necessary to manage sexual health issues, possibly as a result of the awkwardness of discussing sexual topics with parents, teachers, and friends; the inhibitions caused by shame, stigma, embarrassment, and fear; and conservative sociocultural norms and religious beliefs [28,29].Furthermore, stigma associated with adolescent sexual behavior, unintended pregnancies, early childbearing, abortion, and STIs can have detrimental effects on one's health and well-being, including shame, social exclusion, violence, and mental illness [30,31].These outcomes can have both short-and long-term negative effects on one's general wellbeing.
Racialized immigrant youth face various unique struggles and barriers in achieving optimal level of health due to the intersecting effects of race, age, gender, and immigrant sta-tus that influence their experiences.A 2007 study by Flicker et al. of 1216 Toronto teenagers, including those from various ethnic backgrounds and recent immigrants, revealed that teens participate in a wide range of sexual behaviours, including kissing, oral sex, and vaginal intercourse [32].The majority of Toronto teens also claim that they have never sought medical attention for anything to do with their sexual health, citing obstacles like their fear of being judged or embarrassed by friends, worries about confidentiality, beliefs about how kid-friendly the services are, parents'/caregivers' reactions, and worries about staff judgement.Flicker et al. (2007) discovered that immigrant kids with three years or less of residence in Canada had marginally lower rates of sexual health education at age 13 and dramatically lower rates by age 18 [32].Additionally, using surveys of 1216 teenagers, researches have investigated the factors that predicted access to sexual health care for urban immigrant adolescents living in Toronto.According to the study's findings, immigrant youth's access to sexual health treatments is influenced by their sexual activity, age, race, and social resources, these findings are similar to the findings of research study conducted by [33].The World Health Organization (WHO) also found a link between women's sexual and reproductive health (SRH) and their mental health in a 2009 review.However, the majority of participants in this review were married, childless women, with few teenagers from middle-and high-income nations [34].
As expected, parts of adolescent growth, sexual activity, and exploration can result in sexually transmitted infections (STIs), unintended pregnancies, dating violence, or abortions, among other undesired health effects [35].Due to numerous obstacles, immigrant teenagers between the ages of 10 and 19 find it difficult to acquire the required sexual and reproductive health information and treatments in Canada [36].Although the impact of SRH events on young people's physical health and well-being is established, it is unclear how much burden may result from the negative effects of sexual experiences on the mental health of young people [37].The purpose of this paper is to explore the perceptions of the relationship between developing sexuality and well-being of Pakistani descent female adolescents, living in a large urban area in Canada in order to offer recommendations for various stakeholders.We also asked participants to offer their recommendations and suggestions to improve support towards their sexuality needs.In conducting our study, we opted for the term "sexuality" instead of 'sex", in order to understand the holistic approach to the subject, not limited to the sphere of sexual reproductive health, which includes various themes for instance critical thinking, gender roles and stereotypes, relationships and emotions, and different sexual orientations and identities, etc. [38].
As Canadian society becomes more diverse, there is a need for research that will assist health care providers and service providers in becoming more sensitive and responsive towards the needs of the diverse groups that they serve.The area of sexuality among female immigrant adolescents in Canada has been one that has been neglected in both practice and research.This dearth in knowledge and in services has become even more evident for the Pakistani immigrant community, who represent a group with potentially unique and diverse needs related to sexual health.Moreover, the existing literature on socio-cultural issues, race, patriarchy, and the influence that they have on how first and second-generation Pakistani adolescent females perceive and experience their sexuality suggests that Pakistani female immigrant adolescents as a group warrant attention in research related to sexuality.The present study seeks to address the gap in our understanding about the sexuality experiences and needs of Pakistani-descent female adolescents living in Canada.

Method
We conducted a qualitative study to describe perceptions and experiences of developing sexuality in middle-to late-female adolescence of Pakistani-descent living in an urban center in Canada.To explore the complex phenomena of adolescent sexuality, an interpretive descriptive (ID) approach was used to explore the contextual and experiential knowledge adolescent sexuality and their well-being [39].The qualitative study included individual interviews with first-or second-generation Pakistan-descent female adolescents (n = 21).This paper reports qualitative findings regarding participants' perceptions on developing sexuality and well-being and their views on how their sexuality experiences can be supported during the adolescence years.This study received ethics approval from the University of Alberta Research Ethics Board.
For this study, we used principles underlying both postmodern feminist and intersectionality approaches [40,41].Both theories examine how social and cultural categories interact on several, and often simultaneous, levels.During the data analysis, these principles enable us to identify how injustice and inequality exists on various levels for racialized youth and that affects female immigrant adolescent sexuality and their well-being.
Moreover, the authors used reflexivity throughout the research process that involves examining their own judgments, practices, and belief systems during the data collection process.The goal of being reflexive was to identify any personal beliefs that may have incidentally affected the research.

Sample and Data Collection
A purposive sample of 21 female adolescents who were first-or second-generation Pakistan-descent was obtained.The call for participation was circulated through recruitment material such as emails, flyers, posters, and social media platforms such as Twitter, Instagram, etc., containing information about the study, eligibility criteria, and researcher name and contact information.Female adolescents who were willing to participate in the study contacted the researcher directly.Additionally, snowball sampling was used as a strategy to recruit female adolescents.The interpretive description approach, a qualitative research design, was used to examine and interpret sexuality experiences in female adolescents.Ethical approval for the study was obtained from the Human Research Ethics Board of the University of Alberta.The participants included were female adolescents aged from ages 14 to 19 years who were willing to share their experiences with the researcher.
Data were collected using a semi-structured interview guide and a timeline.Timelines are developed from important life events of a study participant, positioned in a sequential fashion, with a visual demonstration of the importance or meaning attached to a particular event.A total of 28 in-depth interviews including 7 follow-up interviews were conducted.Follow-up interviews were conducted to gain more in-depth understanding of participants perspective during the analytical process.Initially 10 interviews were organized in a private space and all other interviews were conducted via an online video conferencing platform due to the COVID-19 pandemic restrictions.Written informed consent and confidentiality agreement were obtained before the interview and ongoing reminders regarding consent by the researcher reinforced the confidentiality of participants.The interviews lasted 90 min on average.The interviews were audio-recorded and transcribed with any identifying information removed.An interview guide is attached as Appendix B.

Data Analysis
Interpretive description offered an inductive approach toward understanding the phenomena of adolescent sexuality and well-being.Inductive reasoning, continuous engagement, testing, challenging initial interpretations, and conceptualization were all steps in the data analysis process that helped us grasp the phenomenon [39].The data analysis method adopted was a thematic analytic one [39].The second interview was followed by the start of data transcription and translation.Upon completion of transcription, repeated immersions in the data identified emerging categories, linkages, and patterns in the data.NVivo 1.5 version was used for data analysis, different categories, linkages, and patterns in the data were identified.Overarching themes were developed and discussed with the research team to further explore meanings.Continual interaction with the data and the keeping of an audit record of all methodological and analytical choices made during the investigation helped to keep the study credible and trustworthy.

Findings
The demographic findings The demographic information of all the study participants is shown in Appendix A. The narratives revealed that participants' concerns about their physical and psychological wellbeing intertwined with their experiences of developing sexuality.Especially a lack of exposure to adequate sexual health education affected them in several ways by shaping their physical, psychological, and sexual health.Participants also talked about the need for and importance of having access to information about these issues and voiced their concerns about having parental participation in better supporting their sexuality.

Sexuality and Wellbeing
Participants described various challenges related to experiencing various controls over their behavior and sexuality.Participants expressed that the messages received about sex and the body were often negative or ambivalent.Indirect communication from parents led some participants to feel unsure about themselves and their bodies.Participants mentioned that mobility restrictions followed by menarche isolated them socially and make them lonely without support and guidance; "I have nobody to share my feelings and experiences with" [P4, 14 years old].This lack of autonomy to make choices was triggering hopelessness among participants.
Due to the lack of knowledge about puberty, the majority of participants expressed that menarche was an unpleasant experience.The start of puberty makes female adolescents ashamed of physical and sexual changes; "the start of my menstruation was an abrupt and upsetting incident for me" [P12, 17 years old].Another girl mentioned that "I was shocked after my first period; it was a terrible feeling. . . .I avoided my mother because I was too embarrassed to talk about it with her." [P11, 15-year-old girl] One of the participants in our study who grew up in Pakistan mentioned the use of drugs under the influence of her boyfriend and how it affected her physical and mental wellbeing.She mentioned that "I was in my first relationship with my best friend's brother . . . he used to do drugs and forced me to do it too . . . he used to threaten me. . .I didn't know back then about the importance of consent . . .I was too scared to tell my parents . . .this affected my health, social life as well as my education" [P9, 19 years old] According to the participants in the study, a lack of knowledge and skills to protect themselves from sexual harassment makes them fragile and weak.To avoid being blamed, participants usually remain silent about sexual harassment.Early marriage and consequent loss of freedom worry them.Participants expressed that all kind of control over their sexuality leads to frustration that ends up in problems like disturbed sleep and dietary pattern along with anxiety, stress, and, in extreme cases, even depression.
The majority of participants experienced psychological changes associated with puberty that were related as experiences of anxiousness, sadness, depression, nervousness, and misery.Communicating anything related to sexuality with parents was viewed as problematic by most participants.One of the participants mentioned that "there is no point of talking with my parents on sexuality issues, as they wont trust me, I always prefer to turn to my friends on such things".Participant's narrative revealed they believe that their parents are unable to recognize their concerns as well as they do not want to comply with parental advice, want independence, lack trust in the family, feel confused about their role, and prefer to be with peers.
In their narratives, participants expressed their awareness of the consequences they can face for disobeying the boundaries of acceptable behavior within their cultural system.Participants in the study expressed their disappointment that their sexual rights were tightly controlled by their parents by setting certain limits on them due to cultural differences such as prohibiting them from dating, talking with boys, or from any sexual activity.For example, many participants spoke of their parents' denial to allow them to sleep over at friends' houses, even for all-girl parties.All the participants mentioned similar limitations, that is, parental restrictions over their physical mobility that they believe are to control of their bodies.
One participant who was 14 years old mentioned that "my mother does not allow me to wear like short skirts or tank tops, even in summer she wants me to wear full-cover clothing... Another girl expressed that, "I guess my mother think if I wear short clothes boys will look at me or do something wrong."[P14, 17 years old].These were some controlling measures that were forced on participants by their parents.
Although anxiety among children and parents is a normal part of adolescence and is not exclusive to immigrants, these tensions become more pronounced when it came to culturally sensitive matters.For instance, a couple of participants had arguments with their parents about going to the junior prom at their school.Due to what the participants perceived as concerns about an unfamiliar culture, the parents had forbidden their daughters from attending any such gatherings.As a girl noted, "My father explicitly said, I can't go to prom or parties because of what my parents think might happen after, like getting drunk or have sex" [18 years old].This view was supported by another girl "I really wanted to go to prom as all of my friends were going, but my parents didn't allow it as they think what might happen after the dance, this is what they see in movies and heard stories about . ... But these were not my intentions . . .

I only wanted to enjoy with my friends" [P17, 17 years old]
Parental control also led some participants to hide their interactions with others and use of communication devices.One of the participants while remembering one of the events expressed how her mother used to scrutinize her chats and monitor everything, she said "Well, my mom was monitoring me.I started making other accounts like I made an art account and that wasn't allowed, but she didn't know that existed . . .whenever she wasn't around, I just go incognito mode . . .hang out on that account.I had stopped playing online games for a bit, so she couldn't really scrutinize that."[P3, 18 years old].She further mentioned "I used to like hide everything, I had an iPod.They [parents] used to think I just use it for music and, um, mobile games because I used to be very extreme in hiding things.I had ways to hide the apps.I had locks on top of those hidden apps . . .I would always log out of my every single account."[P3, 18 years old] These unpleasant experiences let this girl suppress her feelings for girls or boys to prevent herself from any kind of judgment from her parents.She spoke "I think I am, or I have become asexual; I was very open about my asexuality because . . . it was sort of like an anti-shame thing for me . . . it was less shameful for me to be like asexual than like anything else, even straight."[P3, 18 years old] One participant who identified herself as bisexual shared her experience of hiding her sexual identity from their parents due to fear of resentment as she thought their parents would disown her, she mentioned that "I don't want them (parents) to know just out of like, just knowing that or like the thought of them not supporting it.It's like better to not risk that in my opinion.I don't know, because I depend on them financially and like for support in other ways, like emotional support and just like the way that you do depend on families.So, for me, keeping that like to myself is worth it."[P12, 17 years old] The feelings of fear of family rejection were also described by another participant who identified as a lesbian and shared that fear and stigma of being lesbian and being rejected by parents has caused her stress and depression."I've actually been to therapy for two years now. . .and I'm also on medication.So yeah, all of that really helped and like kind of, I've also been to support groups, like survivor groups that have helped" [P18, 19 years old] One girl while mentioning the unfortunate situation where her mother found out about her boyfriend, and she had to end her relationship sadly expressed "I don't think I got over that crush, even though I denied it for like several years and it's only very, very, very recently that I kind of snapped out of my denial.But I'll probably get into that later.Um, but yeah, that guilt was very strong.But throughout junior high, I had a lot of secret friendships."[P10, 19 years old] The participates shared that these sexuality-related experiences and the need to hide them from their parents were accompanied by negative emotions such as fear, apprehension, distress, and an overall reluctance to reveal their thoughts and actions to their parents.The stories of participants reflected that throughout their adolescence age, parental control and expectations had continued to influence their experiences, behavior, and beliefs related to sexuality and the meanings that they attribute to them.
According to participants in the study, control over their sexuality leads to many negative consequences on their sexual health.Participants indicated that the lack of sexuality education, knowledge, and skills had harmful impacts such as decreased sexual desires, becoming involved in risky sexual behavior, and resulting STIs, and an impact on future relationships.The availability of information about sexuality and sexual health was a huge concern for the female adolescents in this study.Few participants raised questions about being able to make informed decisions about their sexuality.A 19-year-old participant expressed her worry saying that "Very soon my parents would want me to marry without having any information on family planning methods, I think this could be very harmful to my future relationship with my husband".[P12, 17 years old] A 19-year-old participant indicated that "My all elder sisters got married by age 22, I know that's my fate too, but I am not ready for it, as I have no confidence in making sexual and emotional choices" [P18, 19 years old].Most of the participants mentioned that they have never been, or they never want to be in any kind of sexual relationship before marriage.However, lack of knowledge prevented female adolescents from making informed sexual health choices.
The stories that participants told indicated that the lack of access to information and services related to sexuality impacts their sexual health and ambivalence about acceptance of culturally prescribed role.Many participants shared that they had to go through various types of sexual harassment and dating violence due to the lack of knowledge about consent.They also shared that they were not able to share the incident with their parents due to fear of being blamed.
Another participant talked about her reluctance in seeking medical help when she was facing an irregular period.She described her story when she was unable to tell her mother that she has not had her period in the last 4 months, she said "despite not being in any sexual relationship, I thought that my mother would think that I am pregnant".She further expressed "I don't know what I was thinking, I was just going through PCOs, I was finally diagnosed when I was 17".[P9, 19 years old] She suggested that this situation would have been easily avoided if her mother had simply kept such conversations normal at home.
In their narrative, participants indicated that, due to the silence around sexuality at home and fear from parents in speaking about sexuality, they have started to suppress their concerns related to sexual health.A participant in a study mentioned that "I have just started to ignore my concerns related to sexual health . . .because I know there is no one who can listen and answer my questions without judgment. . .I am scared of asking questions from my parents" [P8, 18 years old].
The analysis indicated that controlling immigrant female adolescents' sexuality played a significant part on the participants experiences of well-being.

Female Immigrant Adolescents' Perceptions and Suggestions
Female adolescents' voices are presented with reference to their perceptions and suggestions about how their parents could help to normalize and support their sexuality experiences during the adolescent years.Despite many complex challenges, female adolescents faced regarding their sexuality, they felt that they received minimal or inadequate support from adults on how to navigate resources with regard to their sexuality.The key themes that emerged under the study are breaking silence around sexuality, nonjudgemental and blame-free attitude, and sexuality conversations open, honest, and free from stigma.

Breaking Silence around Sexuality
Female adolescents in the study expressed their concern about the taboo and silence around the topic of sexuality from their parents.Many participants share their disappointment by saying that their parents are great role models and educate them about every aspect of their lives, yet they are very reluctant and unwilling to talk about sexuality with female adolescents.A 17-year-old girl shared "I think sometimes they [parents] can definitely make an effort to talk about these things [sexuality], but like what I saw with my parents, they tried, but it was very vague, and it was like very general . . .I just feel very judged.Like they felt like if I did this, I would feel very judged Like I would be doing something wrong in their eyes."[17 years old] Similarly, a couple of participants who had difficulty discussing about sexuality stated her views about parents to be more open in discussing sexuality "I've definitely had like some conversation with my parents about like how we need to be a lot more open. . . .In Pakistani culture, there's the whole idea of getting married at very young age and then not having the sense, not having like any education before that.And I think at least before you get married, you should have a very explicit talk about sex and like consent and all of that and how that plays a role into your romantic life and your future life in general" [18 years old] "My mother sometimes gives me hidden messages, which are never explicit by giving me examples of other girls in the community like what they did wrong and its consequences, I get some idea, but my questions are always unanswered.I eventually end up searching for my answers on google and get a lot more information on sexuality, I feel guilty as I think I am too young to know too much" [16 years old] Female adolescents indicated that the silence or hidden message about sexuality they receive at home affects their lives negatively.The participants also mentioned that as a result of negative connotations attached to sexuality, they are going through feelings of shame, fear, and regret after being exposed to sexual experiences.A 19-year-old girl who had faced sexual harassment at a very young age expressed that "Child should feel like they could be able to approach their parents no matter what and be able to talk to them.Like how I wish I would have my mom the whole time" [19 years old] Most participants who had an opportunity to discuss sexuality with their parents indicated that it was usually only briefly touched.Participant's voices strongly proposed that the female adolescents perceive parents to be most uncertain to discuss the topic of sexuality with them and that many parents entirely avoid this topic or move the responsibility onto others such as aunts and schoolteachers.

Non-Judgemental and Blame Free Attitude
Study participants reported that attempts to indulge in discussions about sexuality often resulted in a judgemental attitude or that parents make justifications not to talk about sexuality.This gives way to female adolescents starting to doubt themselves, leaving them with questions on whether they are allowed to talk to parents and the consequence of such conversations.As one of the participants mentioned that "If I discuss anything with my mother, it is mostly about menstruation or physical bodily changes, other than that its hard to find words to discuss things around sexuality . . .because I put myself in trouble once when she found some posters in my bag which I got from high school fair, and she started asking questions in a very judgmental manner" [15 years old] Another girl expressed her worry about how desperately she would like to speak to her mother, but how she was countered by numerous internal questions that they ask themselves about whether they can trust parents enough to open up to them without being met with confrontation and judgement.Participants further mentioned that parents usually perceive questioning about sexuality as an indication that their daughters are sexually active or have a desire to be.This kind of behavior from parents prevents female adolescents from exploring more on sexuality and make it very difficult for female adolescents to view sexuality in a positive way.A 17-year-old girl who identified herself as lesbian expressed her views on how parents should facilitate their children's choices "Parents should let them [children] explore and the child find out who they are and letting their child be who they are, is so important and . . .telling them that any part of them is wrong is isn't okay.This makes the child to hate themselves, makes your child like have psychological issues.And it's something that not just like people here in general are sick or do something wrong, the fact is that it's normal [LGBTQ community], it's normal and it shouldn't be shamed, and it should not be taboo."[19 years old] Participants in the study explicate that they want their parents to approach the topic of sexuality in a way that is non-judgmental and free from blame.This will provide an opportunity for female immigrant adolescents to explore their queries and receive adequate information on sexuality.

Sexuality Conversations: Open, Honest, and Free from Stigma
Young immigrant girls may benefit from regular, thorough, and nonjudgmental dialogues about their sexuality that allow them to participate more fully.Young girls feel unhappy because it appears like parents only chat when they have to and cut off the conversation when they still feel the desire to hear more.It's possible that parents stop talking to their kids about sexuality as soon as they start to feel uncomfortable."It's like my mother is always scared to talk about it.Generally, she avoids any such [sexuality] conversation or she wants to get it over abruptly.She will just say you are not attending sex-ed class, it is rubbish and then she won't answer any questions.And if I ask anything, my mom say, 'No, I don't want to talk about it', or something like that."[17 years old] Participants in the study indicated that they would prefer to be approached by their parents in an honest and open way and prefer these discussions to happen gradually at home and during routine check-ups, frequently.Participants also mentioned that they want trusted and respected relationships with their parents and health care providers, so they do not feel shame while discussing sexuality.
"I think parents need to be more open and approachable because you are bringing up your kids.They're not just coming here [to Canada] for education . . .you can't have education without socialization or like, meeting new people.And I feel like coming to Canada, you're not just getting the education, you're getting the people, you're getting the values again, the beliefs."[17 years old] Participants clearly do not want parents to talk in understatements and to step casually around the topic of sexuality.Participants would like these conversations to be open so that they can be adequately informed in order to make their choices.A 19-year-old girl who was constantly pressured by their parents to follow Pakistani culture and values voiced her views "As much as you [parents] want your kids to grow up like you grew up in Pakistan, like family values wise . . .But you need to understand that this is a whole new community that your child is exposed to, they will never be exposed to your culture [Pakistani culture], they will like listen about it but they'll never like lived through it.So, I feel like just being more understanding of what a child is going through, although it may be a little difficult to have certain conversations, . . . it is necessary to have them with the child or else you like in the end . . .your child is feeling distant from you." [18 years old] Another girl who had a similar experience while growing up stated that "You[parents] came here for a reason it's for education.Right?But like you have to sacrifice some things.because you're growing up in an area [western world] where people are more open, things are talked about unlike in Pakistan.I didn't go to school in Pakistan, but I don't know the sex ed was like a big thing there, but I don't think it is.And here you're more open to it, you are put into a school with boys and girls, and you have recess with boys and girls and stuff like that.And I feel like people need to be aware of that.And there's no such thing as girls with girls, boys with boys here.because they're trying to bring you up into an equal and fair world.Parents should be more open to expecting change from their kids and accepting the change too."[18 years old] The study participants believed that immigrant parents are ignorant about the broad topic of sexuality because they think that their children would forget their culture and religion and will eventually adopt western values.A 17-year-old girl expressed her views "there's that concern that you're going to forget about your culture and religion.And I think that's on the top of the mind of every parent that they're going to forget about religion and culture.That's why they opt them out of these things to basically like hide them or conceal everything religion doesn't agree with.But I think you have to accept that this is just biology.It's not even just, it's not even culture, it's just biology and you just have to learn about it."[17 years old] An 18-year-old also articulated that "Parents have this perspective that it's the Canadian people here that are going to ruin your children and are going to teach them all this stuff [about sexuality] and that you have to keep them away from these people.Whereas I feel like this society has probably helped me more than my own community, . . . the idea that it's the Canadians or the Americans or the Western world that's going to guard, your child, or whatever like mess your kid up.It's probably not, I think just need to be more open and have more discussions to prevent kids from going off the track."[18 years old] A 19-year-old participant, who according to her suffered a lot while growing up in terms of dealing with differences with parents in learning about sexuality, stated her advice for immigrant female adolescents that "For adolescents, I would say, even if you're not allowed to go to sex-ed class because of your parents or whatever, it's so easy to educate yourself these days, um, through the internet or through university or whatever, it's just you keep yourself informed.Don't be ignorant.Like, don't just keep your eyes close to these things because that's not going to make them disappear."[19 years old] It is noteworthy to mention that participants in this study expressed their desire regarding their parental presence and listening ears to have conversations about sexuality.They explicitly highlighted the need for support and guidance from trusted adults, particularly their parents, to discuss sexuality more frequently, comfortably, openly, explicitly, and with confidence.

Discussion
This paper reports qualitative findings regarding participants' perceptions on developing sexuality and overall well-being and their views on how their sexuality experiences can be supported during the adolescence years.The narratives revealed participants' concerns about their physical and psychological wellbeing intertwined with their experiences of developing sexuality.In particular, lack of exposure to adequate sexual health education affected them in several ways by shaping their physical, psychological, and sexual health.Participants also talked about the need for and importance of having access to information about these issues and expressed their concerns about having parental participation in better supporting their sexuality.
The findings of this study relate to the ways that Pakistani immigrant female adolescents connect their sexuality experiences with their overall well-being.Their stories point to a complicated process that takes into account environmental, systemic, and personal elements in addition to and independent of cultural influences.Due to conflicting signals they received about sexuality, immigrant young girls residing in Canada are substantially more likely to have mental health issues [37,42].Similar to how prejudice, exclusion from sex education classes, and a lack of information about sexual health can lead to exclusion from social settings, avoidance of medical care, and poor mental health outcomes for these participants.
At the same time, physical and mental health issues linked to sexual health can go without treatment or care due to fear and lack of communication with parents about sexuality, or because they cannot find a provider who can understand and speak to their needs and realities as immigrant individuals [43].The results are in line with earlier research on South Asian females, which shows that discussing sex is frequently accompanied by humiliation, guilt, a fear of being derided, and worries about breaching societal norms [14,44].Moreover, experiences of homophobia or transphobia, when growing up in traditional Pakistani household and the resultant loss of community and family support that would likely come from revealing culturally unacceptable gender identities can impact over all well-being of immigrant adolescents [45].
Having support from parents and the community can result in better health outcomes across the board and help minimize the experiences of loneliness and isolation among these female adolescents.The behavioral control over sexuality that these female adolescents experience in their daily lives give rise to issues like lack of confidence, low self-esteem, self-conscious, insecurity, fear, and anxiety.It is clear from the data that due to control over their sexuality, immigrant female adolescents often feel vulnerable to poor psychological health [46,47].The intersectionality perspective entails an explicit recognition of the essentialized norms of power and privilege, as well as norms of inequity and oppression [48,49].The intersectional approach helped us in identifying silencing and invisibility of immigrant female adolescents' sexuality in order to demand their voice and inclusion.Our study participants also spoke about how their sexuality-related needs can be supported, emphasizing the importance of listening to their voices [50].
Participants expressed that their parents are generally unwilling to speak about sexuality.Yong girls are left in the dark, misinformed, and open to abuse as a result of this silence.Similar to earlier research, participants reported feeling blamed and shamed by adults for wanting to talk about their sexuality, and most of the time, adults (parents or instructors) instill fear in them by emphasizing the negative effects of sex [51].The participants are also aware of any signs of hostility and resentment when they try to talk about sexuality.Participants felt adults are likely to assume that young girls who talk about sex are often sexually active, which they undoubtedly dislike given their views on sex abstinence [52].
Participants offered their recommendations about what they want from adults when talking about sexuality: (1) parents, schoolteachers, and health care workers to be less ignorant about the sexual health topic; (2) to develop positive relationships and trust to allow open conversations around the topic of sexuality in an age-appropriate and timely manner; (3) conversations related to sexuality be free of interrogation and be accurate without sneaking around the topic; and ( 4) to provide open discussion about striking a balance between exploring sexuality and the boundaries of social and cultural values.Generally, we found that female adolescents expressed interest in learning more about sexuality in open, honest, and non-judgmental ways.
Research also suggests that parents can positively shape these attitudes and behaviours for their adolescents and are a powerful source of information on sexuality.Therefore, we recommend that parents should have training opportunities to learn adequate information on sexuality so they can acquire effective skills to communicate these issues with their children.Moreover, adults, particularly sexual health educators like parents or schoolteachers, should be confident when discussing the issue of sexuality with adolescents.To achieve this, it is important for adults to be self-aware of their own values that hinder them in promoting healthy sexuality among female adolescents [53,54].As a result of this, female adolescents will have the liberty to explore, embrace, and responsibly enjoy their sexuality, and this will prevent them from any kind of negative health outcomes.
While the same services and supports are available to all youth, the low level of service utilization among immigrant youth is an indicator of service accessibility barriers [55].For racialized youth, the fear of stigmatization from health care providers and disclosing their sexual or gender identity prevent them from receiving care.In addition, female immigrant adolescents are less likely to seek out sexual and mental health support than other adolescents [56][57][58] mostly due to cultural and societal expectations.The current study reveals that timely and appropriate access to sexual health education and mental health counseling can benefit female adolescents who are experiencing psychological problems including stress and anxiety due to cultural and religious influences.When parents let their daughters make informed decisions about their own sexuality, this can be accomplished easily.This study provides preliminary qualitative evidence that experiences of immigrant adolescent sexuality can impact their wellbeing and that support from their parents can play a critical role in enhancing their wellbeing.Future qualitative and quantitative studies are necessary further delineate strategies that can attenuate the negative experiences of adolescent sexuality as described in this study and improve communication between Pakistani immigrant adolescents and their parents.However, we acknowledge the fact that in some cultures having a dialogue about sexuality is taboo especially in countries with strict gender roles such as Pakistan.It would be uncomfortable or inappropriate for parents with strong religious beliefs to discuss sex or sexual health with their children openly.

Limitations
We identified few limitations in our study.Research has found that being physically present during the interview process and the development of timelines helped in building rapport with participants.However, due to COVID-19 restrictions, most of the interviews were completed via Zoom, therefore, researchers were unable to be physically present with the participant.As a result, it took time and extra effort to make participants comfortable in making timelines and sharing their stories on a sensitive subject of sexuality while they were home and surrounded by other family members.Moreover, the findings of this study should be interpreted under the context of immigrant female adolescents living in Edmonton, Alberta.Experiences of immigrant youth may be different from those who live in other parts of Canada.Our study sample represents experiences of mostly late adolescent girls (16-19 years), so further longitudinal research is needed at various intervals of the early, middle, and late adolescence stages to identify similarities or variations in the experiences of sexuality in immigrant population.Also, future work can be undertaken to explore the perspectives and experiences related to sexuality among adolescent boys, challenges of immigrant parents, and healthcare professionals dealing with immigrant populations.

Conclusions
Due to the overlaps between female gender and sociocultural realms of influence, developing sexuality can be a significant source of stress and worry for Pakistani immigrant female adolescents.Our study provides evidence of the potential intersection between female immigrant adolescents' experiences with sexuality and their impact on their overall well-being.The female adolescents' voices in this study indicated that when planning and implementing interventions to support immigrant female adolescents' sexuality, it is crucial to involve, listen to, and incorporate female adolescents' voices on how they need adult support with regard to sexuality.We propose that mastering self-regulatory abilities may be strengthened by successfully navigating emerging sexuality, and that female adolescents can use this to make better decisions about their physical, sexual, and psychological health.This study also argues the existing assumptions about the mutual exclusivity of "sexuality" and "mental health" in adolescence, and we suggest that parents, health educators, and health care providers can leverage sexuality to support the health promotion of immigrant female adolescents more effectively.

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If no, why?

6.
In your journey of developing sexuality, what are some things that you found helpful, or what supports would you wish to have?
Any other comments or suggestions?

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I always think twice If I have any questions in my mind regarding sexuality . . .like what if she will judge me forever about what I tell her?Is it acceptable to talk about it?Can I tell her?I think its better to use the internet to find my answers" [14 years old]