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Generational sex and HIV risk among Indigenous women in a street-based urban Canadian setting Bingham, Brittany; Leo, Diane; Zhang, Ruth; Montaner, Julio; Shannon, Kate 2014

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Generational Sex And HIV Risk Among Indigenous Women In AStreet-Based Urban Canadian SettingBrittany Bingham1,3, Diane Leo4, Ruth Zhang1, Julio Montaner1,2, and Kate Shannon1,2Kate Shannon: gshi@cfenet.ubc.ca1Gender and Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS, Vancouver, Canada2Department of Medicine, University of British Columbia, Vancouver, Canada3Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada4Downtown Eastside Sex Workers United Against Violence Society, Vancouver, CanadaAbstractIn Canada, indigenous women are overrepresented among new HIV infections and street-basedsex workers. Scholars suggest that Aboriginal women’s HIV risk stems from intergenerationaleffects of colonisation and racial policies. This research examined generational sex workinvolvement among Aboriginal and non-Aboriginal women and the effect on risk for HIVacquisition. The sample included 225 women in street-based sex work and enrolled in acommunity-based prospective cohort, in partnership with local sex work and Aboriginalcommunity partners. Bivariate and multivariate logistic regression modeled an independentrelationship between Aboriginal ancestry and generational sex work; and the impact ofgenerational sex work on HIV infection among Aboriginal sex workers. Aboriginal women (48%)were more likely to be HIV-positive, with 34% living with HIV compared to 24% non-Aboriginal.In multivariate logistic regression model, Aboriginal women remained 3 times more likely toexperience generational sex work (aOR:2.97; 95%CI:1.5,5.8). Generational sex work wassignificantly associated with HIV (aOR=3.01, 95%CI: 1.67–4.58) in a confounder model restrictedto Aboriginal women. High prevalence of generational sex work among Aboriginal women and 3-fold increased risk for HIV infection are concerning. Policy reforms and community-based,culturally safe and trauma informed HIV prevention initiatives are required for Indigenous sexworkers.KeywordsCanada; Indigenous ancestry; women; sex work; HIV/AIDSIntroductionIt is impossible to give meaning to research concerning Indigenous women globally andtheir risk of HIV without consideration of the historical context including the legacy ofCorrespondence to: Kate Shannon, gshi@cfenet.ubc.ca.NIH Public AccessAuthor ManuscriptCult Health Sex. Author manuscript; available in PMC 2015 April 01.Published in final edited form as:Cult Health Sex. 2014 ; 16(4): 440–452. doi:10.1080/13691058.2014.888480.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptcolonialism, racialised polices, forced removal and displacement from land, homecommunities and the devastating impact on disconnection from traditions, spirituality andculture (Dion Stout and Kipling 2003; Smith 1999; Browne and Fiske 2001). Common tothe more than 370 million Indigenous people in the world is the powerful effect ofcolonisation on the health of their people and their communities (Gracey and King 2009).The gap in health between Indigenous and non-Indigenous peoples is not unique in Canadabut is present globally, with Indigenous people bearing the disproportionate burden ofdisease, disability and death (Gracey and King 2009).In Canada, the legacy of colonisation and historical trauma, including the residential schoolsystem and child welfare policies has resulted in a ‘soul injury’ that continues to be felt bythe youngest generations of Aboriginal people (Duran, Duran, Yellow Horse and YellowHorse 1998; Dion Stout and Kipling 2003). However, despite this historical legacy oftrauma and social disconnection, there remains a paucity of data on vulnerability acrossgenerations, and its relationship to HIV risk among Aboriginal peoples. Of particularconcern, despite the documented overrepresentation of Aboriginal women within visible,street-based sex work in Canada’s urban centres (Amnesty International 2009; Spittal et al.2002), and the devastating number of lives lost through violence and murder over the lastdecades, there is a surprising silence in public policy and research on the voices andstruggles of Aboriginal women who are street-entrenched, living in poverty, and engaged insex work.The global HIV epidemic disproportionately impacts marginalised groups of people, racialand ethnic minorities including Indigenous people. The socioeconomic inequalities faced byIndigenous people include: poverty, substance misuse, homelessness and unequal access tohealth care lead to an increased risk for HIV infection (Gracey and King 2009; Marshall2008). Aboriginal women continue to bear the disproportionate burden of ill health andaccount for almost three times more AIDS cases than their non-Aboriginal counterpartsacross Canada (Barlow 2003). Between 1998 and 2006 Aboriginal females represented 48%of positive HIV tests (Barlow 2009).Despite evidence of the increased vulnerability to HIV among women, few preventionstrategies are gender sensitive, and even fewer have focused on Aboriginal women withinstreet-based sex work in Canada’s urban centres. Furthermore, few public policies andresearch studies specifically consider the synergistic effects of historical trauma andAboriginal women’s risk for HIV, particularly for street-entrenched women engaged in sexwork. Aboriginal women in Canada experience rates of violence 3.5 times higher than non-Aboriginal women, in particular women involved in sex work are at heightened risk ofviolence (Amnesty International 2009; Shannon, Kerr et al. 2009). In the DowntownEastside of Vancouver, Canada, a low-income area known for the drug and low track sexwork being prominent, over 60 women have gone missing since the 1980s, one third ofwhom were of Aboriginal ancestry (Amnesty International 2009). One man has beencharged with the murders of 22 women, and he is suspected to be responsible for thedisappearance of many more (Carter 2005). Many of the missing women were engaged insex work and it has been estimated that up to 70% of street sex workers on the DowntownEastside are Aboriginal, in their early 20s and also mothers (Culhane 2003; Shannon, Bright,Bingham et al. Page 2Cult Health Sex. Author manuscript; available in PMC 2015 April 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptGibson et al. 2007). Aboriginal women on the Downtown Eastside continue to fight forvisibility, justice and to have their voices heard. To date, Aboriginal women who compriseclose to half the population of street sex workers in Vancouver remained almost completelyignored in both public policy and research despite their unique historical context anddisproportionate vulnerability. High rates of trauma and violent victimisation have beendocumented among both Aboriginal and non-Aboriginal women in sex work (Shannon,Strathdee et al. 2009; Shannon, Kerr et al. 2009; Vaddiparti et al. 2006; Stoltz et al. 2007;Mill 1997). Street involved Aboriginal women’s experiences differ from their non-Aboriginal counterparts in that they live with historical trauma resulting from the turbulenthistory of racial policies in Canada which is further compounded by contemporary racialisedpolicies which create the context within which they work and live. Little or no research hasinvestigated the generational nature of vulnerability and its associated HIV risk amongAboriginal women engaged in street-based sex work.Historical Legacy of Colonisation and Racial PoliciesIn Canada, the residential school system removed over 100,000 children from their familiesbetween 1874 and 1986 (Pearce et al. 2008). As recently as 1991, 13% of Canada’sAboriginal populations were residential school survivors (Dion Stout and Kipling 2003).Attempts to “civilise” Aboriginal people became an official government policy in the 1840s.The government was attempting to prevent any interference with their plans to coloniseWestern Canada (Dion Stout and Kipling 2003). There were 22 residential schools in BritishColumbia, which was more than in any other Canadian province. Residential schools usedregimented behaviour, corporal punishment and strict discipline to teach Aboriginal childrento be ashamed of their culture, language and Aboriginal identity. Aboriginal children inresidential schools were subjected to many forms of abuse at the hands of school employees,including sexual abuse (Pearce et al. 2008; Dion Stout and Kipling 2003; Barlow 2003). Thedisciplinary regime often involved verbal, sexual or physical assault and there are alsodocumented cases of children being confined in dark closets, being beaten physically orhaving their heads shaved for speaking their native language (Dion Stout and Kipling 2003).The residential school regime created a general climate of fear for the children and taughtthem to be ashamed of their culture as well as their family. The impact of residential schoolsis felt at the individual, family and community level (Evans-Campbell 2008). Manyindividual survivors of residential schools adopted destructive patterns of behaviour andmany died an early death as a result of suicide, violence or alcohol-related causes (DionStout and Kipling 2003). The patterns of behaviour learned in residential schools were oftenbrought back to families and communities creating a cycle of violence and abuse impactingfuture generations of children.Survivors of residential school often indicate that their experiences in the residential schoolsleft them unprepared to become parents themselves. Being raised in an institutional settingwith authoritarian care givers and a lack of emotional support left survivors facing difficultyshowing affection to their own children (Dion Stout and Kipling, 2003). After being takenfrom their parents at young ages, survivors did not have the chance to learn child-rearingand parenting techniques from their own parents:Bingham et al. Page 3Cult Health Sex. Author manuscript; available in PMC 2015 April 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript“Like a pebble dropped in a pond, the effects of trauma tend to ripple outwardsfrom victims to touch all those who surround them, whether parents, spouses,children or friends”(Dion Stout and Kipling 2003 p. 33).The legacy of residential schooling in Canada is still felt by the youngest of Aboriginalgenerations. The trauma resulting from residential schools, whether direct orintergenerational, continues to have an impact on Aboriginal people, intersecting with theirissues of mental health, drug use and risk taking behaviours leading to HIV vulnerability.The residential school era was followed closely by the cultural assimilation policies of thechild welfare system in Canada. In the 1950s, the federal government handed over control tothe provinces for Aboriginal health, education and welfare. Each province was givenpayment for each First Nations child apprehended (Fournier and Crey 1997). In 1959, only1% of all children in care were First Nations and by the end of the 1960s close to 40% wereFirst Nations. This number is shocking when considering that at this time, First Nationspeople only made up less than 4% of the national Canadian population (Fournier and Crey1997). The large numbers of Aboriginal children apprehended over that 30 years wasdubbed the “sixties scoop” by Patrick Johnson (Bennett et al. 2005, p. 19). Children wereplaced in foster care and rarely returned home, growing up with little understanding of theirculture and were often discriminated against in cities or towns where very few Aboriginalpeople resided (Bennett et al. 2005; Fournier and Crey 1997). Many children also sufferedphysical or sexual abuse at the hands of their foster parents or adoptive parents. Somechildren were apprehended for legitimate reasons of abuse but many were apprehendedbecause of impoverished living conditions or because they required medical care. Theremoval of children from First Nations communities was devastating and many communitieslost an entire generation of their children to the child welfare system (Bennett et al. 2005;Fournier and Crey 1997). Generations of First Nations children who suffered the effects ofthe child welfare system are now dealing with issues of identity, searching for their parents,culture and communities, and trying to heal from the trauma of abuse.Generations of Aboriginal communities have been affected by Canadian policies ofassimilation and the disproportionate number of Aboriginal women and families who arestreet involved requires urgent investigation and intervention. Little is known aboutAboriginal women’s experiences in sex work and if generational involvement in sex workdiffers between Aboriginal and non-Aboriginal families given this historical context.Research has consistently reported the trauma that affects many Aboriginal people inCanada combined with entrenched poverty, racial discrimination and cultural losses, highrates of violence, mental health problems and substance abuse (Varcoe and Dick 2008;Culhane 2009). Little or no research has specifically investigated Aboriginal women’spathways to sex work involvement particularly within a familial context. Culhane (2009)highlights the complexities of analyses, policies and interventions aimed at improvingAboriginal health resulting from the vast differences with and among Aboriginal groups.Within the inner city setting Aboriginal residents are more disadvantaged when compared tonon-Aboriginal residents and furthermore, Aboriginal women face the most challengesrelated to absolute and relative poverty (Culhane 2009; Varcoe and Dick 2009). AboriginalBingham et al. Page 4Cult Health Sex. Author manuscript; available in PMC 2015 April 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptwomen’s rates of HIV, injection drug use, and involvement in the most visible, street-basedaspects of sex work continue to be higher than for other identified sub-populations inVancouver’s inner-city however their voices and perspectives are often not considered indiscussions about solutions to reducing health and social inequities (Culhane 2009).Aboriginal women’s pathways into sex work and experiences working in sex work are asignificant gap in the research literature. Given the paucity of data, we examined theexperiences of generational sex work involvement (having a mother, sister, aunt, brotherwho exchanges sex on the streets as a means of survival) among Aboriginal women and theindependent effect on risk for HIV acquisition.MethodsData are drawn from a community-based HIV research cohort focused on evaluating theindividual, social and structural contexts of HIV risk among women in street-based work inVancouver, British Columbia. A detailed description of the community engagement,development and methodology of the project have been published elsewhere (Shannon,Bright, Allinott et. al. 2007). Briefly, since 2005, academic researchers and community havepartnered in developing and implementing the research, including collaborators from sexwork agencies, Aboriginal and women’s organisations. Between April 2006 and May 2008,252 women were recruited and consented to participate in a prospective cohort study(response rate of 93%), including baseline and bi-annual interview questionnaires andvoluntary HIV screening. Given the difficulty in accessing a representative sample of sexworkers, time-space sampling strategies and mapping were used to enhance attempts atobtaining a sample representative of women in street-based sex work. Eligibility criteria wasdefined as being a woman age 18 years and older who smoked or injected illicit drugs(excluding marijuana) and actively engaged in street-level sex work. At baseline, a detailedsemi-structured questionnaire was administered by trained peer researchers (Aboriginal andnon-Aboriginal women with current/former sex work experience) elicited responses relatedto demographic characteristics, mobility, drug use patterns, health and addiction service use,violence and safety, and sexual and drug-related harms.Dependent VariablesOur dependent variable was ‘generational sex work’ defined as having a family member (e.gmother, sister, aunt, brother) currently or previously engaged in street-based sex work.Given substantial overlap between having various family members, for the purposes of thisanalysis, we created a dichotomous variable of yes or no to having family engaged in sexwork. Follow up research may further investigate the impact of different patterns ofgenerational sex work involvement on vulnerability to HIV and other outcomes. In oursecondary analyses, our dependent variable was HIV seropositive status based on point ofcare rapid INSTI® test (Biolytical Laboratories Inc., Richmond, BC: specificity =99.3%;sensitivity=99.6%) conducted by the project nurse and confirmed by western blot. Allparticipants received standardised pretest and posttest counseling.Bingham et al. Page 5Cult Health Sex. Author manuscript; available in PMC 2015 April 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptCovariates of InterestIndividual, interpersonal and contextual factors were considered in the following analysis ascovariates of interest. Age was considered a continuous variable (years), and Aboriginalancestry was defined as ‘yes’ versus ‘no’. It is acknowledged that the category ‘Aboriginal’does not fully capture the diversity of the Indigenous populations of Canada however for thepurposes of the current study participants who self-identified as being Aboriginal areincluded in the analysis within the ‘yes’ category. Individual drug use patterns includeddaily cocaine and heroin injection, crystal methamphetamine use (injection/non-injection),daily crack use and sharing of syringes or drug paraphernalia. Being homeless before age 16and living in the inner-city epicentre were also considered as individual variables of interest.Interpersonal/contextual variables of interest included servicing a high number of clients perweek (10+ vs. less), ever experienced physical violence, ever experienced childhoodphysical violence, and ever experienced childhood sexual violence.Statistical AnalysesDescriptive statistics and bivariate analyses were conducted to test for associations withgenerational sex work involvement. The Pearson’s chi-square test was used to verifyassociations between each independent variable and the outcome measures. A logisticregression model was then fitted to obtain adjusted odds ratios for factors associated withgenerational sex work involvement. Variables found to be associated with generational sexwork involvement at the univariate level (p<0.05) were entered into the logistic regressionmodel. The final model was selected by minimising Akaike Information Criterion (AIC) in astepwise manner, selection started with a model including only a constant and addingpredictor 1 at a time. At each step, the effect on AIC is checked by removing a previouslyadded variable, with a lower value suggesting a better fit (Deering et al., 2013). In oursecondary analyses, we built multivariate confounder models restricted to Aboriginalancestry and non-aboriginal to test for an independent association between generational sexwork involvement and HIV positive serostatus. All reported p-values are two sided and oddsratios (ORs) reported at 95% confidence intervals (CIs).ResultsOf the total sample, 225 women were eligible and included on this analysis. 107 (47.5%)were of Aboriginal/Indigenous ancestry (inclusive of First Nations, Métis and Inuit, andnon-status First Nations). The mean age of participants was 34.3 years and the mean age offirst exchanging sex for money was 18.6 years.Descriptive data for the sample was also stratified by Aboriginal ancestry (see Table 1). Ofthe Aboriginal women in the sample (n=107), 41% had used heroin in the past 6 months and64% reported daily crack use. Sixty-seven percent of Aboriginal women reported they hadborrowed syringe or drug use paraphernalia. Eighty-five percent of Aboriginal womenreported they were living on the downtown eastside compared to 76% of their non-Aboriginal counterparts. Forty-eight percent of Aboriginal women reported experiencingchildhood sexual violence in their lifetime and 34% were HIV seropositive. Aboriginalwomen first exchanged sex for money at a younger age than non-Aboriginal womenBingham et al. Page 6Cult Health Sex. Author manuscript; available in PMC 2015 April 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript(16years vs. 17 years respectively). Non-Aboriginal women were significantly more likelyto have used heroin in the past 6 months.Fifty (22.2%) of the sample reported they had a family member who has exchanged sex onthe streets. Of those who reported generational sex work, (34) 68% were of Aboriginalancestry, compared to (16) 34% of non-Aboriginal counterparts (see Table 2). Among theparticipants who reported generational sex work involvement, 27(54%) reported daily crackuse and 36 (72%) reported having borrowed a syringe or other drug use paraphernalia. Fifty-four percent of participants who experienced generational sex work involvement reportedthey experienced homelessness before age 16 compared to only 39% of those who had notreported generational sex work involvement. Eighty-four percent of those who reportedgenerational sex work involvement reported they lived on the downtown eastside comparedto 79% of those who had not experienced generational sex work involvement.In a multivariate logistic model (Table 2) generational sex work was associated withAboriginal ancestry (adjusted OR=3.05, 95% CI: 1.47–6.33), homeless before 16 years ofage (OR=2.95, 95% CI: 1.4–6.24), older age (aOR=1.04, 95% CI: 1.00–1.08), and inverselyassociated with heroin use in the past six months (aOR=0.24, 95% CI: 0.11–0.52). In aconfounder model restricted to women of Aboriginal ancestry, adjusting for age, earlysexual abuse, homelessness and injection drug use, generational sex work remainedindependently associated with HIV infection (OR=3.01, 1.67–4.58). There was nostatistically significant association between generational sex work and HIV infection amongnon-aboriginal participants.DiscussionOur results demonstrate that women of Aboriginal ancestry were three times as likely toexperience generational sex work involvement, irrespective of other risk factors. Further, wefound that generational sex work involvement holds an independent confounding effect thattriples the risk for HIV infection among Aboriginal women. This is a risk pathway notobserved among non-Indigenous sex workers. As previously noted, HIV prevalence amongAboriginal women stands at one-third of street-based sex workers (34%) compared to onequarter among non-Aboriginal women. These findings underscore the urgent need forattention by policy makers, including Indigenous leaders, governments, and HIV preventionand human rights experts.This study offers critical insight into the downstream effects of the historical andintergenerational legacy of colonisation and racial policies in Canada on our Indigenouscommunities and these legacies’ impacts on shaping the HIV epidemic for Aboriginalwomen. The silence and lack of acknowledgement within our communities on the visibleoverrepresentation of Aboriginal women among the most marginalised aspects of the sexindustry, requires immediate consideration. Further community-led research into howgenerational sex work shapes HIV risks for Aboriginal women as compared to Caucasianand visible minority women is warranted. These results provide important evidence tosupport evidence-based calls to move away from a criminalised approach to prostitution inCanada towards a public health and human rights-based approach. In particular, our findingsBingham et al. Page 7Cult Health Sex. Author manuscript; available in PMC 2015 April 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptsuggest the importance of Aboriginal voices and leaders in policy reform and HIVprevention efforts.It is difficult to fully comprehend how the nature of generational sex work involvementamong Aboriginal sex workers shapes experiences of trauma and HIV risk. What remainsclear is that the legacy of residential schooling and historical trauma crosses generations andcontinues to impact cycles of young Aboriginal women. Mill (1997) conducted a qualitativestudy with Aboriginal women and found that HIV risk behaviours became survivaltechniques for these women. The women described histories of turbulent familyrelationships, parental residential school experiences, parental substance abuse, physical andsexual abuse and negative foster care experiences. Women often reported running away at ayoung age, using substances including injection drugs and first exchanging sex duringadolescence. Simoni, Sehgal and Walters (2004) echo these findings and highlight theimportance of previous life trauma, including intergenerational trauma in the prevention ofHIV infection among Aboriginal women. This study found that women who weretraumatised would use injection drugs as a way to cope with abuse and their drug usemediating the relationship between past non-partner trauma and current sexual risks for HIVinfection. Aboriginal women in the current study were no more likely to report risky druguse (e.g. cocaine, heroin injection, syringe sharing) than their non-Aboriginal counterparts,however Simoni and colleague’s (2004) work suggests that this injection pathway maymediate the impact of trauma on sexual risks for HIV infection among Indigenous women.Collectively, these findings suggest an urgent need for immediate action. Research andpublic health approaches that utilise decolonising methodologies and Aboriginal-ledinitiatives (including leadership by Aboriginal communities) are urgently required as acritical buffer to sexual risks and HIV infection for Aboriginal women. Indigenousmovements towards self-determination are underway and there is growing evidence thatIndigenous people globally benefit from culturally relevant and culturally appropriateinterventions that fit better with Indigenous concepts of health (Lavoie 2004). Culturallyrelevant interventions and increased community ownership can help mitigate the complexconstellation of vulnerabilities faced by Aboriginal people, including HIV vulnerability.Marshall (2008) highlighted the impact of macro-level structural and environmental factorscontextual factors that influence negotiation of sexual risks among marginalised individualsand the importance of considering these factors when planning HIV preventionprogramming. Women of Aboriginal ancestry when compared to their non-Aboriginalcounterparts were more likely to report being homeless before age 16 and report that theyreside on the downtown eastside of Vancouver. Poverty and geographic marginalisation inurban ghettos may suggest in part why young Aboriginal women remain continuouslyoverrepresented in the most visible aspects of sex work across Canada’s urban centres. Todate, hundreds of Indigenous youth and young women have gone missing from the streetsacross Canada, with high rates both in Vancouver and in the north of BC along the highwayof tears, a stretch of highway infamously known for 18 young girls, mostly youngAboriginal women who have been murdered or gone missing since 1969 (Rolston 2010).The Native Women’s Association of Canada reported 582 cases of missing or murderedAboriginal girls and women, and this number is likely underestimated (NWAC 2010). InBingham et al. Page 8Cult Health Sex. Author manuscript; available in PMC 2015 April 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript2001 a police task force was created following years of protests demanding action andjustice for these women. Increased efforts must be made to ensure that the Aboriginal youthand sex workers have access to safe, supportive health and support services.The generational vulnerability of Aboriginal women within the most marginalised, street-entrenched aspects of sex work suggests that criminalised approaches to sex work in Canadahave not only been vastly ineffective at protecting individuals and communities from harmbut further exacerbating marginalisation of this street-entrenched Aboriginal women. Thereis a growing body of evidence of structural conditions including policies and law shape thecontext within which HIV vulnerabilities occur (Blankenship and Koester 2002; Shannonand Csete 2010; Shannon and Montaner 2012; Seshia 2010). Human rights basedapproaches in combination with Indigenous- and sex work-led approaches are needed toensure that the voices of Aboriginal sex workers are included in HIV prevention and policydevelopment. These findings echo global calls, including international policy bodies such asWHO, UNAIDS and the Global Commission on HIV and the Law, to move away from acriminal justice approach to human rights and public health approaches to preventing harmamong sex workers. More research is needed to document the narratives and livedexperiences of Aboriginal sex workers voices to provide a contextual analysis to thegenerational nature of their experiences and document pathways of resiliency against andvulnerability to HIV infection.Several limitations of this analysis should be considered. Firstly, the results are from a cross-sectional survey and therefore causality and direction of associations cannot be determined(Shannon, Bright, Allinott et al. 2007; Shannon, Bright, Gibson et al. 2007). A primarycovariate of interest ‘Aboriginal ancestry’ was defined as ‘yes’ versus ‘no’. ‘Aboriginal’does not fully capture the diversity of the Indigenous populations of Canada including FirstNations, Inuit and M groups as well as both status and non-status populations as definedunder the Indian Act. Further qualitative inquiry is required to further explore the uniqueexperiences of First Nations, Metis and Inuit women involved in sex work. The dependentvariable ‘generational sex work’ as a binary variable does not capture the differencesbetween which family member is involved in sex work or whether there is a variable impactto having one family member in sex work compared to several, which can be considered infurther qualitative inquiry. All behavioural variables are self-reported and can be subject tosocial desirability bias. The study had a low non-response rate (7%) and time locationsampling across sex work strolls has been a standard for accessing hidden populations andthis being combined with community partnerships the study is likely to have reached someof the most marginalised women (Lazarus et al. 2012). Interviews for the current study wereconducted offsite, however all women were initially contacted through a low-threshold dropin centre and therefore the most marginalised women may not have been reached. Thecriminalisation of sex work in Canada creates a hidden population difficult to engage inservices, health care and research. However, the participatory methods employed by thisstudy and mapping has helped ensure that an increasing number of most marginalisedwomen in sex work are reached (Shannon, Bright, Allinott et al. 2007; Shannon, Bright,Gibson et al. 2007).Bingham et al. Page 9Cult Health Sex. Author manuscript; available in PMC 2015 April 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptIn summary, generational sex work among Aboriginal women in street-based sex work isassociated with a 3-fold increased risk of HIV infection irrespective of other risk pathways.Policy reforms and HIV prevention initiatives that are community-based, culturally safe andaddress issues of historical trauma are urgently required for Indigenous street-based sexworkers to stem epidemics of HIV infection. Policies and services that aim to prevent HIVmust also address Aboriginal women’s experiences of violence and promote theirindependence and focus on strengths and resilience through the use of post-colonialapproaches (Varcoe and Dick 2008; Duran and Walters 2004; Mooney-Somers 2011). 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[Accessed on June 1, 2013.] What their stories tellus: Research findings from the sisters in spirit initiative. 2010. http://www.nwac.ca/sites/default/files/reports/2010_NWAC_SIS_Report_EN.pdfPearce ME, Christian WM, Patterson K, Norris K, Moniruzzaman A, Craib KJP, Schechter MT,Spittal PM. and For the Cedar Project Partnership. The cedar project: Historical trauma, sexualabuse and HIV risk among young Aboriginal people who use injection and non-injection drugs intwo Canadian cities. Social Science & Medicine. 2008; 66:2185–2194. [PubMed: 18455054]Rolston, A. Highway of tears revisited. Ryerson Review of Journalism. 2010. http://www.rrj.ca/m8461/Seshia M. Naming systemic violence in Winnipeg’s street sex trade. Canadian Journal of UrbanResearch. 2010; 19(1):1–17.Shannon K, Bright V, Allinott S, Alexson D, Gibson K, Tyndall MW. and for the Maka ProjectPartnership. . Community-based HIV prevention research among substance-using women insurvival sex work: The maka project partnership. 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Associations between childhoodmaltreatment and sex work in a cohort of drug-using youth. Social Science & Medicine. 2007;65:1214–1221. [PubMed: 17576029]Vaddiparti K, Bogetto J, Callahan C, Abdallah AB, Spitznagel EL, Cottler LB. The effects ofchildhood trauma on sex trading in substance using women. Archives of Sexual Behavior. 2006;35:451–459. [PubMed: 16900413]Varcoe C, Dick S. The intersecting risks of violence and HIV for rural Aboriginal women in a neo-colonial Canadian context. Journal of Aboriginal Health. 2008; 1:42–51.Bingham et al. Page 12Cult Health Sex. Author manuscript; available in PMC 2015 April 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptBingham et al. Page 13Table 1Baseline Characteristics of Women in Street-Based Sex Work, Stratified by Aboriginal Ancestry (N=225)Aboriginal AncestryYes (n=107)n(%)No (n=118)n(%)p-valueCocaine injection* 30(28.04) 42(35.59) 0.225Heroin injection* 44(41.12) 68(57.63) 0.013Crystal methamphetamine use* 13(12.15) 17(14.41) 0.619Daily crack cocaine use 69(64.49) 72(61.02) 0.591Receptive use of used syringe or drug paraphernalia 72(67.29) 76(64.41) 0.649>10 clients per/week 33(35.11) 40(35.71) 0.928Homeless <16 years of age 48(44.86) 48(40.68) 0.527Living in the Innercity epicentre 91(85.05) 90(76.27) 0.097Experienced physical violence* 26(24.3) 39(33.05) 0.148Experienced child physical violence 56(52.34) 61(51.69) 0.923Experienced child sexual violence 52(48.6) 58(49.15) 0.934HIV seropositive status 36 (33.6) 28(23.73) 0.025Median age 34 years [IQR1: 24–40] 36 years [IQR: 27–42] 0.020Median age first exchange sex for money 16 years [IQR: 14–19] 17 years [IQR: 14–23] 0.156*= Last 6 Months1IQR= Interquartile RangeCult Health Sex. Author manuscript; available in PMC 2015 April 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptBingham et al. Page 14Table 2Bivariate and Multivariate Associations with Generational Sex Work among Women in Street-Based SexWorkGenerational Sex WorkYes (n=50)n(%)No (n=175)n(%)Unadjusted OddsRatios (95% CI)Adjusted OddsRatios (95% CI)Aboriginal ancestry 34(68.00) 73(41.71) 2.97 (1.53–5.78) 3.05** (1.47–6.33)Cocaine injection* 11(22.0) 61(34.86) 0.53 (0.25–1.10)Heroin injection* 12(24.0) 100(57.14) 0.24 (0.12–0.48) 0.24** (0.11–0.52)Crystal Methamphetamine use* 7(14.0) 23(13.14) 1.08 (0.43–2.68)Daily crack cocaine use 27(54.0) 114(65.14) 0.63 (0.33–1.19)Receptive use of used syringe or drugparaphernalia36(72.0) 112(64.00) 1.45 (0.73–2.88)>10 clients per/ week 13(30.23) 60(36.81) 0.74 (0.36–1.54)Homeless <16 years of age 27(54.00) 69(39.43) 1.80 (0.96–3.40) 2.95** (1.4–6.24)Living in the innercity epicentre 42(84.0) 139(79.43) 1.36 (0.59–3.15)Experienced physical violence* 14(28.0) 51(29.14) 0.95 (0.47–1.90)Experienced child physical violence 24(48.0) 93(53.14) 0.81 (0.43–1.53)Experienced child sexual violence 25(50.0) 85(48.57) 1.06 (0.56–1.99)HIV seropositive status 7(14.0) 45(25.71) 0.47 (0.20–1.12)Median age 36 (IQR1: 25–41) 34 (IQR: 24–39) 1.02 (0.99–1.06) 1.04** (1.00–1.08)*= Last 6 Months**= Variables significant at p<0.05 and adjusted for in multivariate model1IQR= Interquartile RangeCult Health Sex. Author manuscript; available in PMC 2015 April 01.

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