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The Cedar Project : understanding the association between childhood maltreatment and psychological distress,… Pearce, Margo Elaine 2014

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 THE CEDAR PROJECT: UNDERSTANDING THE ASSOCIATION BETWEEN CHILDHOOD MALTREATMENT AND PSYCHOLOGICAL DISTRESS, RESILIENCE, AND HIV and HCV VULNERABILITY AMONG YOUNG INDIGENOUS PEOPLE WHO USE DRUGS IN THREE CANADIAN CITIES by Margo Elaine Pearce MSc. London School of Hygiene and Tropical Medicine, 2009 M.P.P., Simon Fraser University, 2006 B.A., University of Victoria, 2003  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Healthcare and Epidemiology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  December 2014  © Margo Elaine Pearce, 2014   ii Abstract Background: Indigenous leaders are deeply concerned about the adverse impacts of intergenerational and lifetime trauma on their young people, particularly those who use drugs and are vulnerable to HIV and HCV infection. However, few researchers have investigated the complex intersections of trauma, mental health, resilience, and HIV and HCV vulnerability among young Indigenous men and women in Canada.  Methods: This multidisciplinary research was based on information gathered by the Cedar Project,  a cohort of young Indigenous people (aged 14-30) who use drugs in Vancouver, Prince George, and Chase, British Columbia. The qualitative analyses used an interpretive thematic approach to analyze in-depth interviews. The quantitative analyses first evaluated the construct validity of psychometric questionnaires that measured childhood maltreatment, psychological distress, and resilience. Next, those questionnaires were integrated with longitudinal Cedar Project data to assess associations between childhood maltreatment with HIV and HCV vulnerability, psychological distress, and resilience.  Results: The qualitative research highlighted participants’ ongoing struggles with unaddressed childhood maltreatment and the association between emotional pain and HIV and HCV vulnerability. However, participants were actively resisting the negative effects of trauma maintaining hope for a better life. In quantitative analyses, each of the psychometric questionnaires had acceptable fit for the data. In total, 91.7% of the participants had experienced at least one form of childhood abuse/neglect. Longitudinal vulnerabilities associated with specific types of childhood trauma and cumulative trauma experiences included significant drug and sex-related HIV and HCV risks, in addition to HCV infection. Childhood maltreatment, sex work involvement, sexual assault, heavy alcohol use, and injection drug use increased   iii psychological distress, while living by traditional culture decreased psychological distress. Resilience was increased by having grown up in a traditional family environment, and by having access to and being able to speak traditional languages. Conclusion: This research supports the development of comprehensive, Indigenous-directed healing strategies for HIV/HCV prevention that are tailored for young Indigenous people who use drugs. These strategies must address concurrent trauma and mental health, support connections to Indigenous cultural identity, and facilitate understanding of the impacts of the residential school system and intergenerational trauma on family relationships.    iv Preface This statement is to confirm that the work presented in this dissertation was conceived, conducted, analyzed, and written by Margo Elaine Pearce (M.E.P.).  M.E.P. identified the design of the research program, collected significant parts of the data, and performed the analysis of the data. With the guidance and oversight of the Cedar Project Partnership, supervisor Dr. Patricia M. Spittal (P.M.S.), and committee members Dr. Martin T. Schechter (M.T.S.), Dr. Eugenia Oviedo-Joekes (E.O.J.), and Dr. Chris Richardson (C.R.), M.E.P. established the research objectives/hypotheses, conducted all of the analyses, and wrote each chapter. The quantitative data presented in Chapters 6 through 8 was gathered by Cedar Project study staff located in Vancouver, Prince George, and Chase, British Columbia. The qualitative data presented in Chapters 4 and 5 was gathered by M.E.P. Interpretation of the study results presented in Chapters 4 through 8 was helped greatly by the expertise of the Cedar Project Partnership, the Indigenous governance body that oversees all Cedar Project research, ethical, and knowledge translation activities. For the Conclusion chapter (Chapter 9), M.E.P. received a considerable amount of insight and guidance from Earl H. Henderson (Métis and Cree Heritage) who is an Elder, knowledge keeper, therapeutic counselor, scholar, and member of the Cedar Project Partnership. This research was given approval by the Cedar Project Partnership. In addition, it was given ethics approval from the Providence Health Care and University of British Columbia Research Ethics Board (REB certificate number: H11-02101).     v Table of contents  Abstract .......................................................................................................................................... ii	  Preface ........................................................................................................................................... iv	  Table of contents ............................................................................................................................v	  List of tables.................................................................................................................................. xi	  List of figures .............................................................................................................................. xiv	  Glossary ........................................................................................................................................ xv	  Acknowledgements .................................................................................................................... xvi	  Dedication ................................................................................................................................. xviii	  Chapter 1: Background, rationale, and objectives .....................................................................1	  1.1	   Background ........................................................................................................................ 1	  1.1.1	   Colonization and the residential school system .......................................................... 1	  1.1.2	   Intergenerational trauma and child maltreatment within Indigenous families ........... 3	  1.1.3	   The continuation of child apprehension via the child welfare system ........................ 4	  1.1.4	   Trauma, stress-coping, and HIV and HCV vulnerability among young Indigenous people who use drugs .............................................................................................................. 6	  1.1.5	   Resilience, trauma, and HIV and HCV vulnerability ................................................. 7	  1.2	   Rationale ............................................................................................................................ 8	  1.3	   Objectives ........................................................................................................................ 11	  1.4	   Overview of dissertation .................................................................................................. 13	  Chapter 2: Literature review ......................................................................................................14	  2.1	   HIV and Hepatitis C vulnerability and infection among Indigenous people in Canada .. 14	    vi 2.1.1	   Epidemiology of HIV infection among Indigenous people in Canada ..................... 14	  2.1.1.1	   HIV vulnerability and risk among Indigenous people ....................................... 17	  2.1.2	   Epidemiology of HCV vulnerability and infection among Indigenous people in Canada ................................................................................................................................... 20	  2.2	   Child maltreatment among Indigenous people in Canada ............................................... 23	  2.3	   Relationship between childhood maltreatment and HIV risk among Indigenous young people in Canada ....................................................................................................................... 26	  2.4	   Mental health and HIV vulnerability among young Indigenous people who use drugs in Canada ....................................................................................................................................... 29	  2.5	   Trauma, resilience and HIV vulnerability among Indigenous young people in Canada . 32	  2.6	   Summary of literature review .......................................................................................... 35	  Chapter 3: Methodology ..............................................................................................................36	  3.1	   The Cedar Project methods .............................................................................................. 36	  3.1.1	   Study design .............................................................................................................. 37	  3.1.2	   Sampling methods and study locations ..................................................................... 38	  3.2	   Dissertation methods ........................................................................................................ 42	  3.2.1	   Qualitative setting and participants ........................................................................... 42	  3.2.2	   Qualitative data collection ........................................................................................ 44	  3.2.3	   Qualitative data analysis ........................................................................................... 45	  3.2.4	   Quantitative data collection instruments ................................................................... 47	  3.2.4.1	   The Cedar Project questionnaire ........................................................................ 47	  3.2.4.2	   Childhood Trauma Questionnaire ...................................................................... 50	  3.2.4.3	   Symptom Checklist-90 Revised ......................................................................... 53	    vii 3.2.4.4	   Connor-Davidson Resilience Checklist ............................................................. 54	  3.2.5	   Quantitative data analysis ......................................................................................... 56	  3.2.6	   Handling missing data ............................................................................................... 58	  3.3	   Ethical considerations ...................................................................................................... 60	  Chapter 4: Narratives of childhood maltreatment and the impacts on family and HIV and HCV vulnerability among young Indigenous people who use drugs in three Canadian cities ........................................................................................................................................................62	  4.1	   Introduction ...................................................................................................................... 62	  4.2	   Objectives and rationale ................................................................................................... 67	  4.3	   Overview of the study ...................................................................................................... 67	  4.4	   Theoretical approach informing the study ....................................................................... 68	  4.5	   Review of study setting, participants, and data collection methods ................................ 69	  4.6	   Analytical approach ......................................................................................................... 70	  4.7	   Quantitative study findings .............................................................................................. 72	  4.8	   Qualitative study findings ................................................................................................ 73	  4.8.1	   Complexity and interconnection ............................................................................... 73	  4.8.2	   Stress-coping strategies in childhood ........................................................................ 83	  4.8.3	   Family separation and dislocation ............................................................................ 88	  4.8.4	   Stress-coping mechanisms later in life, and shifting perspectives on family ........... 91	  4.8.5	   Healing ...................................................................................................................... 98	  4.9	   Discussion ...................................................................................................................... 100	  Chapter 5: “I just think it’s a cycle”: Cycles of trauma and finding the strength to survive among young Indigenous people who use drugs in three Canadian cities ...........................109	    viii 5.1	   Introduction .................................................................................................................... 109	  5.2	   Objectives and rationale ................................................................................................. 112	  5.3	   Overview of the study .................................................................................................... 113	  5.4	   Theoretical approach informing the study ..................................................................... 114	  5.5	   Review of study setting, participants, and data collection methods .............................. 115	  5.6	   Analytical approach ....................................................................................................... 117	  5.7	   Study findings ................................................................................................................ 118	  5.7.1	   Negative self-beliefs ............................................................................................... 119	  5.7.2	   Struggling to break cycles of intergenerational trauma .......................................... 125	  5.7.3	   Acknowledging strengths and making positive changes ........................................ 131	  5.7.4	   Hopes and dreams ................................................................................................... 138	  5.8	   Discussion ...................................................................................................................... 142	  Chapter 6: Understanding the continuing effects of childhood maltreatment on HIV risk among young Indigenous people who use drugs in three Canadian cities ...........................152	  6.1	   Introduction .................................................................................................................... 152	  6.1.1	   Objectives and rationale .......................................................................................... 157	  6.2	   Methods.......................................................................................................................... 158	  6.2.1	   The Cedar Project study design and measures ........................................................ 158	  6.2.2	   Study measures ....................................................................................................... 159	  6.2.3	   Participants .............................................................................................................. 161	  6.2.4	   Statistical analysis ................................................................................................... 161	  6.2.5	   Handling missing data ............................................................................................. 163	  6.3	   Results ............................................................................................................................ 163	    ix 6.3.1	   Sample statistics ...................................................................................................... 163	  6.3.2	   Prevalence of childhood maltreatments and differences between men and women165	  6.3.3	   CTQ subscales and differences in severity between demographic and historical trauma factors ...................................................................................................................... 167	  6.3.4	   Confirmatory Factor Analysis ................................................................................. 173	  6.3.5	   Longitudinal outcomes associated with childhood maltreatment ........................... 175	  6.4	   Discussion ...................................................................................................................... 199	  Chapter 7: Psychological distress and HIV vulnerability among young Indigenous people who use drugs in three Canadian cities ...................................................................................211	  7.1	   Introduction .................................................................................................................... 211	  7.1.1	   Objectives and rationale .......................................................................................... 215	  7.2	   Methods.......................................................................................................................... 216	  7.2.1	   The Cedar Project study design and measures ........................................................ 216	  7.2.2	   Study participants .................................................................................................... 219	  7.2.3	   Statistical analysis ................................................................................................... 220	  7.2.4	   Handling missing data ............................................................................................. 221	  7.3	   Results ............................................................................................................................ 222	  7.4	   Discussion ...................................................................................................................... 254	  Chapter 8: Resilience in the face of HIV vulnerability among young Indigenous people who use drugs in three Canadian cities ............................................................................................268	  8.1	   Introduction .................................................................................................................... 268	  8.1.1	   Objectives and rationale .......................................................................................... 272	  8.2	   Methods.......................................................................................................................... 274	    x 8.2.1	   The Cedar Project study design and measures ........................................................ 274	  8.2.2	   Study participants .................................................................................................... 278	  8.2.3	   Statistical analysis ................................................................................................... 278	  8.2.4	   Handling missing data ............................................................................................. 280	  8.3	   Results ............................................................................................................................ 280	  8.4	   Discussion ...................................................................................................................... 302	  Chapter 9: Recommendations and conclusion ........................................................................318	  9.1	   Summary of study findings ............................................................................................ 318	  9.2	   Strengths and unique contributions ................................................................................ 325	  9.3	   Relevance to the community .......................................................................................... 327	  9.4	   Limitations ..................................................................................................................... 337	  9.5	   Conclusion ..................................................................................................................... 337	  Works cited .................................................................................................................................339	     xi List of tables  Table 4.1: Frequencies and severity levels of maltreatment experiences measured by the Childhood Trauma Questionnaire among Cedar Project participants (n=30)* ............................ 72	  Table 6.1: Baseline characteristics and CTQ subscale severity levels among all participants (n=266) and chi-square comparisons between males (n=126) and females (n=140) ................. 164	  Table 6.2: Descriptive comparisons of historical trauma and demographic factors by CTQ subscales (chi-square tests) and total maltreatment summary score (t-tests) among all participants (n=266) ........................................................................................................................................ 168	  Table 6.3: Standardized loadings for the first and second order confirmatory factor analysis of the Childhood Trauma Questionnaire among all participants (n=266) ...................................... 173	  Table 6.4: Bivariate Pearson Correlations of the five-factor Childhood Trauma Questionnaire model among all participants (n=266) ........................................................................................ 175	  Table 6.5: Baseline and longitudinal observation counts for all participants (n=266), male participants (n=126) and female participants (n=140) ................................................................ 176	  Table 6.6: Longitudinal outcomes associated with childhood emotional abuse among all participants (n=266), males (n=126), and females (n=140) ........................................................ 179	  Table 6.7: Longitudinal outcomes associated with childhood physical abuse among all participants (n=266), males (n=126), and females (n=140) ........................................................ 183	  Table 6.8: Longitudinal outcomes associated with childhood sexual abuse among all participants (n=266), males (n=126), and females (n=140) ........................................................................... 187	  Table 6.9: Longitudinal outcomes associated with childhood emotional neglect among all participants (n=266), males (n=126), and females (n=140) ........................................................ 190	    xii Table 6.10: Longitudinal outcomes associated with childhood physical neglect among all participants (n=266), males (n=126), and females (n=140) ........................................................ 193	  Table 6.11: Longitudinal outcomes associated with the childhood maltreatment summary score among all participants (n=266), males (n=126), and females (n=140) ....................................... 197	  Table 7.1: Baseline means and standard deviations (SD) of the SCL-90-R symptom dimensions and Global Severity Index (GSI) among all participants (n=202), and comparisons (t-tests) between males (n=95), and females (n=107) .............................................................................. 224	  Table 7.2: Standardized loadings from first and second order Confirmatory Factor Analysis of the SCL-90-R  symptom dimensions among all participants (n=202) ....................................... 225	  Table 7.3 Bivariate Pearson correlations between the baseline SCL-90-R symptom dimensions..................................................................................................................................................... 229	  Table 7.4: Bivariate Pearson correlations between baseline SCL-90-R symptom dimensions and CTQ subscales ............................................................................................................................ 229	  Table 7.5: Means, standard deviations (SD) and average changes in the Global Severity Index (GSI) among all participants (n=202) ......................................................................................... 231	  Table 7.6: Means, standard deviations (SD) and average changes in the Global Severity Index (GSI) among male participants (n=95) ....................................................................................... 231	  Table 7.7: Means, standard deviations (SD) and average changes in the Global Severity Index (GSI) among female participants (n=107) .................................................................................. 231	  Table 7.8: Coefficient estimates (β), standard errors (SE), and associated t-values and p-values for each study variable on the GSI among all participants (n=202) ........................................... 234	  Table 7.9: Coefficient estimates (β), standard errors (SE), and associated t-values and p-values for each study variable on the GSI among male participants (n=95) ......................................... 241	    xiii Table 7.10: Coefficient estimates (β), standard errors (SE), and associated t-values and p-values for each study variable on the GSI among female participants (n=107) .................................... 248	  Table 8.1: Baseline proportions, mean CD-RISC scores and standard deviations (SD), and mean CD-RISC score comparisons between study factors (t-tests) among all participants (n=191) .. 282	  Table 8.2: Standardized loadings based on first and second order Confirmatory Factor Analysis of the CD-RISC among all participants (n=191) ........................................................................ 286	  Table 8.3: Bivariate Pearson correlations between CD-RISC factors among all participants (n=191) ........................................................................................................................................ 287	  Table 8.4: Bivariate Pearson correlations between baseline CD-RISC factors and the Childhood Trauma Questionnaire maltreatment scores among all participants (n=191) ............................. 288	  Table 8.5: Bivariate Pearson correlations between the baseline CD-RISC factors, and the SCL-90-R symptom dimensions among all participants (n=191) ....................................................... 289	  Table 8.6: Means, standard deviations (SD), and average change in the CD-RISC score over time for all participants ....................................................................................................................... 291	  Table 8.7: Means, standard deviations (SD), and average change in mean CD-RISC for male participants (n=95) ...................................................................................................................... 291	  Table 8.8: Means, standard deviations (SD) and average change in the CD-RISC score for female participants (n=107) .................................................................................................................... 291	  Table 8.9: Coefficient estimates (B), standard errors (SE), and associated t-values and p-values for each model predicting the effects of study variables on CD-RISC scores among all participants (n=191) .................................................................................................................... 295	     xiv List of figures Figure 6.1: Childhood sexual abuse by parental attendance at residential school among all participants (n=266) .................................................................................................................... 171	  Figure 6.2: Childhood physical neglect by parental attendance at residential school among all participants (n=266) .................................................................................................................... 172	     xv Glossary Childhood maltreatment  The experience of emotional abuse, physical abuse, sexual abuse, emotional neglect, or physical neglect in childhood Indigenous person  A descendant of the First Nations Peoples of North America; including Indigenous, Aboriginal, Métis, First Nations, Inuit and Status and non-Status Indians HCV  Hepatitis C Virus HIV  Human Immunodeficiency Virus Psychological distress  Unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope Resilience  Positive adaptation despite adversity    xvi Acknowledgements First and foremost, I would like to extend my heartfelt gratitude to the brave young men and women who participate in the Cedar Project. Your courage has made this work possible. In addition, the Cedar Project study team must be thanked for their dedication and conviction in this work. I would like to express my deep appreciation to Dr. Patricia Spittal for inviting me to be a part of her research team in 2005. This has been an tremendous and life-changing opportunity, as Dr. Spittal has not only trained me in health sciences but also challenged me to be a more creative and authentic researcher and advocate. Both professionally and personally, Dr. Spittal has been a steadfast support and I will be forever grateful for that.  I would also like express my thanks to my committee members Dr. Martin Schechter, Dr. Eugenia Oviedo-Joekes, and Dr. Chris Richardson. Throughout this work you have generously given me excellent direction, encouragement, and thoughtful contributions, for which I am very fortunate.  This work would not have been possible without guidance from Elder, knowledge keeper, and scholar Earl Henderson (Métis and Cree Heritage), Elder Violet Bozoki (Lheidli T’enneh Nation), and Kukpi7 Wayne Christian (Splats’in te Secwepemc Nation). I appreciate you for your wisdom and patience, and for helping me to understand the relevance of this research to the community. In addition, thank you to Cedar Project Study Coordinator Vicky Thomas (Wuikinuxv Nation) for your mentorship, friendship, and for being a source for inspiration and truth.  Funding for this research was generously provided by the Canadian Institutes of Health Research (CIHR), the Michael Smith Foundation for Health Research, the Integrated Mentorship   xvii Program in Addictions Research Training, and the University of British Columbia. I have also been supported by the CIHR-Institute of Aboriginal People’s Health and the Canadian Association of HIV/AIDS Research in order to attend international and national conferences and present this research. My colleagues Sheetal Patel, Kate Jongbloed, Basia Pakula, Alden Blair, and Stephen Pan have been sources of motivation, reassurance, and humour for which I am very grateful. I have also been fortunate to have many dear and brilliant friends who kept me afloat during this entire experience. In particular: Bill Price, Kara Whitlock-Rambo, Alex Beck, Rebecca Lash, Michelle Kelm, Greer Nelson, Adina Edwards, David Wigmore, and Graeme Hamilton. I don’t know where I’d be without friends like you. Finally, my beautiful sister Mandy Hamilton and my devoted parents Lainie and David Pearce are my foundations. Words cannot express the depth of my gratitude to my family for your love, loyalty, and endless support.    xviii Dedication This is dedicated to the memory of my Nana, whose compassion, wisdom, and generosity inspires me to this day.  Doris Anna Percy  1915-2006    1 Chapter 1: Background, rationale, and objectives  1.1 Background 1.1.1 Colonization and the residential school system The colonization of North America has spanned over 500 years and involved aggressive political, legal, ideological, and economic agendas to control Indigenous lands and resources and to assimilate Indigenous peoples into European expectations of civilization. Numerous laws and policies – especially the Indian Act of 1876 – confined Indigenous peoples on resource-poor lands and outlawed Indigenous ceremonies and spirituality. The Gradual Civilization Act of 1857 was one of the most damaging pieces of legislation for Indigenous peoples in Canada because it formalized the church-state partnership that would establish the Indian residential school system. Between 1874 and 1996, over 150,000 Indigenous children as young as three years old were forcibly removed from their communities and placed in residential schools as part of a national strategy to “have the ‘Indian’ educated out of them” (Miller, 2009, p. 144). The stated intentions of the system were “Christianizing, moralizing, civilizing, and modernizing Indigenous children” in order to save them from the “inherent deviance” of their Indigenous heritage their Indigenity (de Leeuw, Greenwood, & Cameron, 2010, p. 288). A key goal of the residential school system was to prevent the intergenerational transmission of Indigenous cultural knowledge, which included languages, ceremonies, spiritual practices, and traditions.  It has only been two decades since Canadian social and political discourses have acknowledged the atrocities committed against Indigenous children by the residential school system . Multiple commissions have been mandated to uncover the actions and impacts of the residential school system and confirmed that they were “opportunistic sites of abuse” (Hylton, 2002, p. 367) where children were routinely abused emotionally, physically and/or sexually   2 (Canada, 1996; Milloy, 1999). In addition, the schools instilled a sense of shame in the children about their Indigenous identities, which has resulted in extensive psychological trauma (Law Commission of Canada, 2000; Truth and Reconciliation Commission of Canada, 2012).  The experience of abuse within the residential school system was both widespread and long lasting. Four generations of some Indigenous families attended the residential schools and it is estimated that 70-100% of the children in the schools were abused physically and/or sexually, in addition to being deprived of emotional or physical nurturing (Canada, 1996; Chrisjohn & Young, 1991; Corrado & Cohen, 2003). Further, it is has been revealed that a staggering number of children died in residential schools due to neglect (Kelm, 1998). In British Colombia (BC) alone, at least 4,100 children ranging in age from four to 19 died while attending the schools between 1917-1956 (Walker, 2014).  An estimated 86,000 residential school survivors are currently living in Canada, 35,000 of whom live in BC (Aboriginal Healing Foundation, 2007). Health researchers have begun to investigate the impact of residential school experiences on the mental health effects of individual survivors and their communities. These effects include major depression (Froese et al., 2008; Public Health Agency of Canada, 2006b), post-traumatic stress disorder (Corrado & Cohen, 2003; Söchting, Corrado, Cohen, Ley, & Brasfield, 2007), problematic substance use (Chansonneuve, 2007; Yellow Horse Brave Heart, 2003), and suicidality (Canada, 1995). Further, the intergenerational effects of the system have been identified in younger generations of Indigenous peoples who did not themselves attend residential schools. For example, Bombay (2011) et al. conducted a study that involved 143 Indigenous people in Ontario, Canada, and demonstrated that participants who had at least one parent who had attended residential school   3 experienced significantly more depressive symptoms and greater reactivity to lifetime stressors than those whose parents had not attended residential school.  1.1.2 Intergenerational trauma and child maltreatment within Indigenous families  Researchers widely concur that maltreatment of Indigenous children was uncommon prior to European contact with North America (Gunn Allen, 1986; Manuel & Posluns, 1974; Miller, 2009). However, the abuses of Indigenous children and disruptions of cultural knowledge transmission that occurred during colonization and the subsequent introduction of the residential school system have had severe and enduring repercussions. Most residential school survivors found it tremendously difficult to return to their communities, reconnect with their families, and raise their own children (Chansonneuve, 2005; Lafrance & Collins, 2003; LaRocque, 1994). Many turned to substance use to cope with their stress and unintentionally reenacted what they had experienced in residential school within their own families (e.g. difficulty with demonstrating affection, emotional attachment, resorting to corporal punishment, and physical and/or sexual abuse) (Yellow Horse Brave Heart, 2003). This prompted the cyclical effect of historical and intergenerational trauma, which Indigenous scholars define as collective emotional and psychological injuries that accumulate over the lifespan and extend across generations (Yellow Horse Brave Heart, 2003). Intergenerational trauma continues to manifest in Indigenous communities that struggle with the interrelated crises of family violence, family fragmentation, poverty, addictions, a lack of traditional skills, a lack of role models, and feelings of isolation (Chansonneuve, 2005; LaRocque, 1994; Tousignant & Sioui, 2009). Though there is a dearth of statistical information on the prevalence and rate of childhood maltreatment experienced by Indigenous people, governmental reports and inquiries made by Indigenous researchers have indicated that   4 childhood maltreatment is one of the most disastrous legacies of intergenerational trauma (Blackstock & Trocmé, 2004; Hylton, 2002; Trocmé et al., 2006). Studies carried out between 1989 and 2007 estimated that the prevalence of childhood sexual abuse within Indigenous communities ranged from 23% to 100% (Collin-Vézina, Dion, & Trocmé, 2009). Although these estimates were based on observational studies, they far exceeded the 10% prevalence of sexual abuse that was observed in a nationally representative Canadian sample (Afifi et al., 2014). In addition, the rate of substantiated maltreatment investigations involving Indigenous children conducted by child welfare agencies in Canada is vastly disproportionate to the rate for maltreatment investigations involving non-Indigenous children. The 2008 Canadian Incidence Study of Child Abuse and Neglect reported that the rate of substantiated cases of child abuse and/or neglect was 59.8 per 1000 Indigenous children compared to 11.8 per 1000 non-Indigenous children (Sinha et al., 2011).  1.1.3 The continuation of child apprehension via the child welfare system  The chronic overrepresentation of Indigenous children living in foster homes in Canada has been well documented (Blackstock, 2008; Canada, 1996). Since the 1950s, the Canadian child welfare system has responded to many families struggling with the aftermath of the residential school system by permanently removing tens of thousands of Indigenous children from their families, communities, and cultures and placing them in non-Indigenous foster or adoptive homes (Fournier & Crey, 1997). This process has been exacerbated by the federal government’s per capita funding of provincial child welfare agencies, which incentivizes long-term separations of Indigenous children from their families, communities, and cultures (Blackstock & Trocmé, 2004; Fournier & Crey, 1997; Johnston, 1983; Trocmé et al., 2006).     5 Changes to child welfare policy in the 1990s expanded the number of First Nations child and family services agencies that managed the protection of Indigenous children, primarily for on-reserve families. As a result, successful community-directed models of child protection based on traditional Indigenous teachings and child-care customs have emerged, which have been shown to address familial issues while meeting children’s cultural needs (Simard, 2009). However, the implementation of community services based on these models have been limited because they are required to adhere to provincial child welfare laws, receive little to no funding for preventing family violence or facilitating family reunification, and have little to no jurisdiction to serve off-reserve Indigenous families (Blackstock & Trocmé, 2004). At the same time, critical factors contributing to the overrepresentation of Indigenous children in the child welfare system – poverty, substance use, and inadequate housing – continue to go largely unaddressed (Blackstock & Trocmé, 2004). Consequently, in 2011, Indigenous children comprised 7% of children under age 14 in Canada, but accounted for 48% of all children in foster care (Statistics Canada, 2013). Similarly, in BC, Indigenous children comprised 8% of the population of children in the province but accounted for 52% of the children in foster care (Sinha et al., 2011).  Many Indigenous leaders and scholars perceive the current child welfare system in Canada as a reiteration of the residential school system as a means to dismantle Indigenous families and ways of life (Christian, 2010; de Leeuw et al., 2010; Fournier & Crey, 1997). Both systems forcibly removed children from their families, deprived them of their cultural identity, and prevented them from maintaining connections to family and community. As a result, the child welfare system can be viewed as contributing to new cycles of intergenerational trauma.     6 1.1.4 Trauma, stress-coping, and HIV and HCV vulnerability among young Indigenous people who use drugs Epidemiological data from the Public Health Agency of Canada suggests that the rate of problematic substance use among Indigenous youth and adults in Canada is higher than non-Indigenous people (Public Health Agency of Canada, 2006a). Indigenous authors have explained that young Indigenous people often use substances as a method of stress-coping with historical, intergenerational, and lifetime trauma. Consequently, they may be self-medicating for trauma-related psychological distress symptoms (Barlow, 2003; Walters & Simoni, 2002). This is extremely concerning in light of the fact that Indigenous people in Canada have disproportionately high rates of HIV and/or HCV infection and contract HIV and HCV primarily as the result of injection drug use (Public Health Agency of Canada, 2010b, 2011).  Few studies in Canada and United States (U.S.) have begun to unravel the impacts of historical trauma, childhood maltreatment, and harmful stress-coping responses on Indigenous peoples’ vulnerability to HIV and HCV infection (For the Cedar Project Partnership et al., 2008; Simoni, Sehgal, & Walters, 2004). For example, an analysis by the Cedar Project that involved 543 young Indigenous people who used drugs in Vancouver and Prince George, BC, found significant associations between sexual abuse, having a parent who had attended residential school, and having been in the child welfare system (For the Cedar Project Partnership et al., 2008). The same study found significant relationships between a history of sexual abuse and self-reports of mental illness, involvement in sex work, and vulnerability to HIV and HCV infection. Other research has confirmed that young urban Indigenous people are vastly overrepresented among people who use injection drugs, people involved in sex work, and people living with HIV and HCV infection (BC Centre for Disease Control, 2010; Chettiar, Shannon, Wood, Zhang, &   7 Kerr, 2010; Miller, Strathdee, Spittal, et al., 2006; Oviedo-Joekes et al., 2010; Public Health Agency of Canada, 2010b; Spittal et al., 2012). However, there is still very little understanding of the specific mechanisms through which the lived experiences of historical and lifetime stressors in childhood have influenced the vulnerabilities of young Indigenous people who use drugs over the life course and the subsequent association between these vulnerabilities and HIV and HCV risk patterns. Indigenous scholars recommend that researchers who aim to gain this understanding should use a decolonizing approach that addresses the adverse impacts of colonization, and address historical trauma and other adverse outcomes of colonization, as well as acknowledge the healing traditions and resilience that are inherent to Indigenous cultures (Kirmayer, Simpson, & Cargo, 2003; Lavallee & Clearsky, 2006; Smith, 1999; Walters, Simoni, & Evans-Campbell, 2002). 1.1.5 Resilience, trauma, and HIV and HCV vulnerability Indigenous author Karina Walters described how the process of colonization eroded the “cultural buffers” that had traditionally helped Indigenous people to cope with stress and mediate risk (2002, p. 521). Walters defined cultural buffers as community resources that facilitate traditional health practices, spiritual coping mechanisms, cultural connectedness, and pride in Indigenous identities. In addition, Kirmayer et al. (2014) observed that the residential school and child welfare systems in Canada created significant adversity in Indigenous communities by fracturing the familial and community infrastructures that supported traditional child-rearing practices and the development of healthy individuals.  Nevertheless, Indigenous authors and Elders have also emphasized that many Indigenous cultures, traditions, languages, and identities have survived the devastation of 500 years of colonization (Dion-Stout, Kipling, & Stout, 2001; Henderson, 2008; Korhonen & Ajunniginiq,   8 2006; McIvor, Napoleon, & Dickie, 2009). Literature has suggested that concentrating on the renewal of these cultural resources (or buffers) may represent an effective approach to creating and supporting resilience and mental wellness at the individual, family, and community levels (Chandler & LaLonde, 1998; Dion-Stout et al., 2001; Korhonen & Ajunniginiq, 2006). This potential has reinforced the imperative to gain a better understanding of how access to cultural resources may mitigate the adverse health outcomes of traumatic life stressors among Indigenous peoples – including illicit drug use and HIV and HCV infection (Duran & Walters, 2004; Walters et al., 2002). Exploring cultural sources of resilience and strength may therefore inform the development of culturally-safe therapeutic interventions for healing young Indigenous people who use illicit drugs and may be disconnected from their families, communities, and cultures. As explained by Brascoupé and Waters (2009), cultural safety is based on the principles of respect, trust, and sharing. In health care practice for Indigenous peoples, cultural safety requires practitioners to not only be knowledgeable of Indigenous cultures, values, and traditions, but must also have awareness of the "history that contributes to the contemporary conditions" and ensure that the Indigenous recipient of care "has the power to make decisions regarding their health (or other matters) and also the power to judge if the interaction feels culturally safe" (p.29).   1.2 Rationale  Indigenous leaders are deeply concerned about the adverse impacts of intergenerational and lifetime trauma on their young people, particularly those who use drugs and are highly vulnerable to HIV and HCV infection (Christian, 2010; Christian & Spittal, 2008). However, few researchers have investigated the complex intersections of trauma, mental health, resilience, and HIV and HCV vulnerability among young Indigenous men and women in Canada. The following   9 four critical gaps were identified in the existent research that may inform the development of effective public health responses to young urban Indigenous people who use drugs in BC.  First, very little is understood about the childhood trauma experienced by young Indigenous people who use drugs (both early and later in life) and the stress-coping mechanisms they have subsequently developed. Indigenous scholars point out that it is essential to listen to the knowledge and experiences of young Indigenous people in order to understand where they are coming from (Brant Castellano, 2000). In addition, very little is known about how young Indigenous people are impacted by the interaction between childhood adversities and systemic or structural challenges, such as the child welfare system and poverty (Tousignant & Sioui, 2009). Consequently, there is a need for researchers to conduct research that acknowledges and explores the emotional and psychological impacts of intergenerational and lifetime trauma on young Indigenous people who use drugs and how these impacts shape pathways to HIV and HCV vulnerability.  Second, the impacts of childhood maltreatment on HIV and HCV risk behaviours among young Indigenous people have still not been clearly identified in research. There is a specific need for researchers to investigate the impacts of maltreatment over time among young Indigenous people who use drugs. In addition, as violence is often a gendered phenomenon, the Canadian Institutes of Health Research Institute on Gender and Health have highlighted the need to assess the presence of gender differences in the effects of violence on health over the life course (Canadian Institutes of Health Research, 2010). The epidemiological evidence produced by such studies will generate insight into the longitudinal effects of childhood maltreatment on HIV and HCV vulnerability and infection among young Indigenous people who use drugs in BC.   10 Third, very few studies have investigated the ongoing effects of historical and lifetime trauma and HIV and HCV vulnerability on the psychological health of young Indigenous people who use drugs. Research is needed that examines the temporal associations between vulnerability to HIV and HCV infection and psychological distress among young people who use drugs. Again, because of established differences in the prevalence of psychiatric symptoms between men and women (Derogatis, 1994), gender differences in the association must be examined.  Fourth, few studies have investigated the positive influence of Indigenous culture, language, and ceremony on the mental well-being of young, urban Indigenous people who use drugs. Indigenous scholars have long argued that it is critical for health researchers to focus on cultural factors that promote resilience among young Indigenous peoples as well as buffer the effects of historical and lifetime traumatic stressors and reduce vulnerability to HIV and HCV on young Indigenous peoples (Duran & Walters, 2004). The use of a multidisciplinary approach that combines qualitative and quantitative methods would facilitate the provision of critical information on the relationships among cultural factors and help determine how they enable young, at-risk Indigenous peoples to survive and adapt to the impacts of lifetime and historical adversities. This is particularly important for the health of young Indigenous people who are living in cities and may be disconnected from their home communities, languages, cultures, and spirituality (Andersson & Ledogar, 2008). It is therefore critically important to explore the associations of cultural factors, historical and lifetime traumas, and risk factors with resilience among young, urban Indigenous people who use drugs.    11 1.3 Objectives The following study objectives and associated research hypotheses are addressed in Chapters 4 to 8.   O1: To understand early childhood experiences, family relationships, and the subsequent trajectories that lead to HIV vulnerability over the life course among young Indigenous people who use drugs.   H1.1: Historical trauma plays a strong role in childhood maltreatment histories and family functioning.   H1.2: Histories of childhood maltreatment are strongly associated with the high-risk behaviours for HIV and HCV infection OR with vulnerability to HIV and HCV infection.  O2: To gain a deeper understanding of the processes by which young, urban Indigenous people who use drugs have coped with the stresses of intergenerational and lifetime traumas while facing substantial institutional and structural barriers to positive health outcomes.   H2.1: Histories of childhood trauma are related to current challenges with stress-coping and ongoing vulnerabilities to HIV and HCV infection and other negative health outcomes.  H2.2: Positive stress-coping is associated with access to cultural resources and services that facilitate resilience and healing.  O3: To test the validity of the Childhood Trauma Questionnaire (CTQ) for measuring childhood maltreatment among young urban Indigenous people who use drugs, to assess the association between parental history of residential school and childhood   12 maltreatment, and to explore the longitudinal outcomes (including HIV and HCV infection) associated with different childhood maltreatments and incremental increases in the number of maltreatments.   H3.1: The CTQ has good construct validity for measuring childhood maltreatment.   H3.2: Having at least one parent who attended residential school will be associated with the prevalence and severity of childhood maltreatment.  H3.3: Childhood sexual abuse and physical abuse are the maltreatments that have the greatest effect on HIV and HCV vulnerability over time.  O4: To test the validity of the Symptom Checklist-90-R (SCL-90-R) for measuring psychological distress among young urban Indigenous people who use drugs and to explore the association of historical and lifetime traumas, protective factors, and HIV and HCV-related related risk factors with psychological distress.   H4.1: The SCL-90-R has good construct validity for measuring psychological distress.   H4.2: Childhood maltreatment and high frequency drug use is significantly associated with elevated levels of psychological distress over time.   H4.3: Cultural factors and access to counseling are significantly associated with lower levels of psychological distress over time.   O5: To test the validity of Connor-Davidson Resilience Scale’s (CD-RISC) for measuring resilience among young urban Indigenous people who use drugs, and to explore the associations of historical and lifetime traumas, protective cultural connectedness factors, and HIV and HCV related risk factors on resilience.    13  H5.1: The CD-RISC has good construct validity for measuring resilience.   H5.2: Childhood maltreatment and high frequency drug use are significantly associated with diminished resilience over time.   H5.3: Cultural factors and access to counseling and drug treatment are significantly associated with increased resilience over time.  1.4 Overview of dissertation This dissertation is comprised of nine chapters and takes an multidisciplinary approach to addressing the five objectives listed above. As noted, the objectives are consecutively addressed in Chapters 4, 5, 6, 7, and 8. These chapters were written as manuscripts intended for publication in peer-reviewed journals. Therefore, there is some repetition in terms of the historical context and study methods in each chapter. There are four additional chapters in this thesis. This chapter (Chapter 1) presents the background, rational, and objectives of the research. Chapter 2 provides a review of the literature on HIV and HCV, childhood maltreatment, psychological distress, and resilience among young Indigenous people in Canada. Chapter 3 provides an overview of all the study methods used for this dissertation and describes the three study locations in which the Cedar Project carries out data collection. Finally, Chapter 9 provides a conclusion based on the research findings reported in Chapters 4-8, discusses the study’s strengths and limitations, and makes recommendations for policy directions and public health interventions.    14 Chapter 2: Literature review 2.1 HIV and Hepatitis C vulnerability and infection among Indigenous people in Canada 2.1.1 Epidemiology of HIV infection among Indigenous people in Canada The most recent information from the Public Health Agency of Canada (PHAC) (released in 2011) revealed that the incidence of HIV among Indigenous people in Canada was much higher than the incidence of HIV for all other Canadian ethnic groups and that the situation is worsening. Although Indigenous people comprised only 3.8% of the population in Canada in 2011, an estimated 8.9% (n=6380) of people living with HIV/AIDS were Indigenous people (Public Health Agency of Canada, 2011). This marked a 17% increase in the number of Indigenous people living with HIV/AIDS since 2008. In addition, Indigenous people are overrepresented among people in Canada who have been newly diagnosed with HIV infections. In 2011, Indigenous people constituted 12.2% (n=390) of all people in Canada newly diagnosed with HIV, which corresponded to an incidence that was 3.5 times higher than the incidence of new HIV infection among non-Indigenous people. The epicentre of the HIV/AIDS epidemic in Canada has historically been the province of British Columbia (BC), particularly the city of Vancouver. Although the BC Centre for Disease Control (BCCDC)’s finding that the rate of new infections in BC had reached the lowest point ever in 2012 was encouraging (5.2 per 100,000 population, or 238 cases), Indigenous people continued to be disproportionately over-represented in BC’s HIV epidemic (21.2 per 100,000 population, or 29  new cases in 2012) (BC Centre for Disease Control, 2013). Indigenous people have comprised only about 5% of the province’s total population for the last few decades, but consistently accounted for 12-15% of new HIV infections between 2003-2012.    15 Both the PHAC and the BCCDC have reported that Indigenous women are most severely impacted by the HIV epidemic. In 2010, women comprised 48.1% of all Indigenous people in Canada who newly tested positive for HIV, compared to only 20.7% of non-Indigenous people (Public Health Agency of Canada, 2010a). In 2012, Aboriginal women comprised only 8.6% of BC’s population but accounted for 37.9% (n=11) of new HIV diagnoses for women in the province. In addition, reports have indicated that Indigenous people living with HIV in Canada are far younger than non-Indigenous people living with HIV. One third of the Indigenous people diagnosed with HIV between 1998 and 2006 were under the age of 30, whereas only 21% of non-Indigenous people who tested positive for HIV were in the same age group (Public Health Agency of Canada, 2010a). According to 2012 surveillance data in BC, the 30 to 39 age group had the highest rates of new infections among Indigenous men, (61.0 per 100,000 population) while the 25-29 age group had the highest rate of new infections among Indigenous women (53.6 per 100,000 population) (BC Centre for Disease Control, 2013). Surveillance data since the 1990s has reported that injecting drugs with contaminated equipment (i.e. needles that have been previously used by someone who is HIV positive) is the primary HIV exposure category among Indigenous people in Canada. Between 1996 and 2006, injection drug use accounted for 53.7% and 64.4% of new HIV infections among Indigenous men and women, respectively. In stark contrast, injection drug use accounted for just 14% of new HIV infections among non-Indigenous people in Canada (Public Health Agency of Canada, 2010c). Studies based in BC have also suggested that Indigenous people who inject drugs have a higher likelihood of becoming infected with HIV than non-Indigenous people who inject drugs (Miller, Strathdee, Spittal, et al., 2006; Tyndall et al., 2006). For example, in 2003 a landmark analysis was published that examined HIV risk among 941 people who used injection drugs in   16 Vancouver, BC. The study demonstrated that the incidence of HIV infection among Indigenous participants was double the incidence of HIV infection among non-Indigenous participants (Craib et al., 2003). This research marked a turning point in the understanding of the epidemiology of HIV infection among Indigenous peoples who use drugs in Canada, as it strongly supported what Indigenous authors had long argued: that unaddressed historical, social, and structural determinants of health were escalating Indigenous people’s vulnerability to HIV infection (Barlow, 2003). In addition, HIV/AIDS service organizations in the Northern Health Authority catchment areas in BC have been increasingly concerned about the limited harm reduction services available to the high numbers of Indigenous people who use injection drugs in the north. In 2012, the I-Track analysis of 144 people who injected drugs in the northern city of Prince George reported an HIV prevalence of 17.8% among Indigenous participants, compared to a prevalence of 11.6% among non-Indigenous participants (Shoemaker, Taylor, & Callaghan, 2013). This finding confirmed that the HIV epidemic among Indigenous people who use drugs is not restricted to the Vancouver area, but has extended to the northern regions of the province.  It is important to note that to date, there is little information about the prevalence or rate of HIV infection among Indigenous people who use injection drugs and live in the Interior region of the province, which includes the city of Kamloops and the township of Chase. However, in 2012 the Interior Health Authority reported that the overall HIV incidence in the Interior region was well below the provincial rate (1.5 per 100,000 vs. 6.5 per 100,000, respectively) (Interior Health Authority, 2012). That same year, three (10.3%) of the new HIV diagnoses among Indigenous people in BC lived in the Interior Health Authority catchment area (BC Centre for Disease Control, 2013).     17 2.1.1.1 HIV vulnerability and risk among Indigenous people  The epidemiology of HIV infection among populations who use drugs is complex, as research has identified sources of risk that extend beyond individual, social, and structural factors (Strathdee & Stockman, 2010). This has sparked considerable interest in understanding the vulnerabilities that precede HIV risk behaviours among populations who inject drugs or are at-risk for initiating injection drug use (Farmer, Connors, & Simmons, 1996; Fast, Small, Krusi, Wood, & Kerr, 2010; Shannon et al., 2008; Shannon et al., 2009; Spittal & Schechter, 2001). Research that addresses HIV vulnerability prioritizes “taking into account the characteristics and interactions in which risk takes place” (Delor & Hubert, 2000, p. 1558). HIV-related vulnerabilities therefore do not directly cause HIV infection per se, but rather create a susceptibility to HIV exposure via high-risk behaviours that characterize “risk environments” (Rhodes, 2002, p. 90). For example, studies have addressed the gendered HIV vulnerabilities that arise when younger populations of women who are involved in sex work also engage in drug injection – particularly needle sharing and the frequent use of heroin (Spittal et al., 2003), and the HIV vulnerabilities that arise due to a lack of control over the injection process – including drug binges (Miller, Kerr, et al., 2006; Miller, Strathdee, Kerr, Li, & Wood, 2006) and needing help injecting (Miller et al., 2002).  The above HIV research affirms that obtaining a deeper understanding of the specific vulnerabilities experienced by young, at-risk Indigenous people who use drugs is essential to the advancement of public health programming and HIV prevention efforts. As indicated, very few studies have pursued an in-depth investigation of HIV vulnerability and risk among Indigenous young people in Canada who use drugs, even though their HIV-rates are very high. The Cedar Project, a cohort study of 793 young Indigenous people in Vancouver, Prince George, and Chase,   18 BC, is the only study of its kind in Canada that has examined HIV vulnerabilities in this population. In multivariate analysis it was demonstrated that the participants who were injecting drugs at the 2003 baseline enrolment had increased vulnerability to HIV infection (i.e. higher probability of engaging in high risk behaviours) if they had a history of childhood sexual abuse (OR: 3.7), and were located in Vancouver (compared to Prince George) (OR: 3.2). These participants’ risk for infection (i.e. higher risk of infection due to behaviours that create exposure to the virus) increased slightly with a longer duration of injection drug use (OR: 1.02) (Spittal et al., 2007). Subsequent analyses also revealed that the proportion of female Cedar Project participants who were HIV positive (13.1%) was significantly higher than the proportion of male participants who were HIV positive (4.3%) (p<0.001) (Mehrabadi, Paterson, et al., 2008). Further, this significant difference between men and women remained when the analysis was restricted to only participants who used injection drugs: 8.5% of the male participants who injected drugs were HIV positive compared to 16.7% of the female participants who injected drugs were HIV positive (p=0.037). This confirmed national and provincial epidemiological reports regarding the specific HIV vulnerability of Indigenous women who use drugs, Further, it was highly concerning that approximately 11 to 12 Cedar Project participants were transitioning to injection drug use per year and that vulnerability to initiating injection drug use was highest among those who were involved in sex work (Miller et al., 2011).  As explained by Indigenous authors and scholars, the origins of HIV-related vulnerabilities among Indigenous peoples are rooted in the much deeper issues of historical injustices and intergenerational trauma and therefore must be understood within that context (Barlow, 2003; Vernon, 2001; Walters, Beltran, Evans-Campbell, & Simoni, 2011). This is affirmed by the Cedar Project’s finding that childhood sexual abuse and being female were   19 critical vulnerabilities that elevated the probability of HIV risk among young Indigenous people who use drugs. As Indigenous scholars have explained, these vulnerabilities are the outcome of colonization, cultural genocide, and the residential school system and the effect of these broad determinants on HIV risk among Indigenous young people must be taken into account (Gunn Allen, 1986; Walters & Simoni, 1999). However and as mentioned previously, very little is understood about precisely how the lived experiences of historical and lifetime stressors in childhood have created vulnerabilities over the life course that subsequently increase the risk of HIV among young Indigenous women and men who use drugs.  American Indigenous scholar Karina Walters has suggested that researchers who investigate HIV-related vulnerabilities among young Indigenous people who use drugs apply an ‘Indigenist’ stress-coping coping model. According to Walters, this model must consider that the “associations between traumatic life stressors and adverse health outcomes are moderated by cultural factors that function as buffers, strengthening psychological and emotional health, decreasing substance use, and mitigating the effects of the traumatic stressors” (2002, p. S105). There is a small but growing body of literature that has examined culture as intervention for problematic substance use and trauma among Indigenous people in Canada (McCormick, 2000). However in previous studies in Canada have explored the positive health effects of such cultural “buffers” among young Indigenous people who use drugs. It is therefore critical for public health and HIV prevention efforts to explore cultural sources of strength and resilience that may help promote health and healing among young, at-risk Indigenous people.     20 2.1.2 Epidemiology of HCV vulnerability and infection among Indigenous people in Canada Though reporting Hepatitis C (HCV) infection is mandatory, there are very few sources of research that have investigated the epidemic among Indigenous people in Canada. Available information from PHAC estimated that the incidence of HCV infection was 4.7 fold higher among Indigenous people than non-Indigenous people in Canada between 2002 and 2008 (Public Health Agency of Canada, 2010b). PHAC also reported that, compared to non-Indigenous people living with HCV, a significantly greater proportion of Indigenous people newly diagnosed with HCV had used illicit non-injection drugs (43.8% vs. 52.0%, respectively), had injected drugs (53.6% vs. 67.3%, respectively), and had had more sexual partners (which meant more than one sexual partner) (52.5% vs. 61.3%, respectively).  Provincial surveillance reports from BC do not routinely collect ethnicity information for the prevalence and incidence of HCV. However, compared to the national statistics, studies in BC have suggested that although Indigenous people are overrepresented among individuals in the province who are HCV positive, the difference among Indigenous versus non-Indigenous people in terms of HCV prevalence and incidence is not statistically significant. One recent study conducted among 940 street-involved youth <30 years old (23.8% Indigenous ethnicity) in Vancouver who used drugs found that although HCV prevalence was higher for Indigenous than non-Indigenous participants (30% vs. 23.1%, respectively) the difference was non-significant (Hadland et al., 2014). Similarly, a Alavi et al. (2014) conducted a study of 2913 randomly selected adults (32% Indigenous ethnicity) in Vancouver’s downtown east side community and reported that the prevalence of HCV was higher among Indigenous participants than non-Indigenous participants (66% vs. 62.6%, respectively), but the difference was not statistically   21 significant. Nevertheless, the authors reported that Indigenous participants who were HCV positive had a significantly decreased likelihood for HCV treatment uptake than non-Indigenous participants (OR: 0.26). This suggests that structural and social factors within the health care system (i.e. racism) may be contributing to young Indigenous people’s reluctance to seeking HCV treatment (Browne & Fiske, 2001; Currie, Wild, Schopflocher, Laing, Veugelers, et al., 2013).  These results are also similar to the results of studies on HCV infection in northern BC. In Prince George, a report from the I-Track study of people who inject drugs also demonstrated that the difference in HCV prevalence between Indigenous and non-Indigenous people who used injection drugs in 2012 was non-significant (65.4% vs. 66.7%, respectively) (Shoemaker et al., 2013). There is no information regarding the ethnicity or mode of transmission for HCV infections in the Interior region of BC, which includes the city of Kamloops and the township of Chase. However, in 2011 the incidence of HCV infection in the Interior was slightly above the rate for the province (43.6 per 100,00 vs. 42.1 per 100,000, respectively) (Interior Health Authority, 2012).  Research from the Cedar Project has also contributed to what is known about the vulnerabilities associated with new HCV infections among young Indigenous people who use injection drugs in BC. For example, 34.8% of participants were HCV positive in the study’s baseline analysis. When the analysis was stratified by injection drug use, HCV prevalence was 59.4% among participants who had ever injected drugs, which confirmed national reports regarding the elevated prevalence of HCV among Indigenous people who inject drugs. In multivariate analysis the risk of HCV infection at baseline was significantly increased by high   22 frequency opiate injection (OR: 2.7), reusing needles (OR: 2.4), and injecting drugs for a longer period of time (OR: 1.4).  One of the Cedar Project study’s most important findings was that among the young Indigenous participants who injected drugs, vulnerability for HCV infection increased if they had at least one parent who had attended residential school (OR: 1.9) (Craib, Spittal, Patel, Christian, Moniruzzaman, Pearce, Demerais, Sherlock, & Schechter, 2009). This supports the standpoint of Indigenous scholars and leaders who have long contended that young Indigenous people who use injection drugs are coping with unaddressed historical, social, and structural health stressors that have increased their vulnerability to sex- and drug-related risks for both HIV and HCV infection (Barlow, 2003; Vernon, 2001; Walters & Simoni, 2002).  An incidence analysis addressing HCV infection among Cedar Project participants demonstrated that the HCV rate was 26.3% per year for participants who had been injecting drugs for less than 2 years and 5.1% per year for participants who had been injecting for more than 5 years. Although this difference could be partially attributed to survivorship bias, the rapid acquisition of HCV within the former group was alarming. The adjusted analysis revealed that the incidence of HCV infection was also significantly higher among participants who were involved in sex work (Hazard Ratio (HR):1.59), had been injecting drugs for less than two years (HR: 4.1), injected cocaine daily or more (HR: 2.47), and shared needles (HR: 2.56) (Spittal et al., 2011).  In sum, the studies referenced in this section emphasize that the high prevalence and incidence of HCV among Indigenous young people who use drugs in BC is related to multiple vulnerabilities such as historical trauma, and risks such as injection use. The results of these studies provide a strong rationale for research focused on improving our understanding of the   23 pathways by which young Indigenous people who use drugs have become vulnerable to infectious disease is required.   2.2 Child maltreatment among Indigenous people in Canada Scientific inquiry into childhood maltreatment among Indigenous people are scarce. However, Indigenous scholars have suggested that a disproportionately high number of Indigenous people in Canada have experienced childhood maltreatment as a consequence of historical and intergenerational trauma (Cedar Project et al., 2008; Chansonneuve, 2005; Hylton, 2002; Nechi Institute, 2002). A degree of insight into this issue has been provided by The Canadian Incidence Study of Child Abuse and Neglect (CISCAN), a PHAC-funded study that examined the incidence of reported child abuse and neglect in Canada (Public Health Agency of Canada, 2010a). The study gathered information about the first contacts between the families of children who entered the foster care system, the children themselves, and child welfare agencies over a three month period in 2008. In addition, the CISCAN included an Indigenous focus by gathering information on child welfare investigations involving Indigenous children that were conducted by 89 provincial/territorial agencies and 22 First Nations (on-reserve) and urban Indigenous agencies (Sinha et al., 2011). The final weighted sample included 14,114 investigations involving First Nations children and 83,650 investigations involving non-First Nations children.  The CISCAN demonstrated that the rate of substantiated cases of child maltreatment was higher for Indigenous children than to non-Indigenous children (Sinha et al., 2011). The rate of substantiated neglect for Indigenous children was 8 times higher than the rate of substantiated neglect for non-Indigenous children; the rate of exposure to intimate partner violence was 4.7   24 times higher, the rate of emotional maltreatment was 5.7 times higher, the rate of physical abuse was 2.1 times higher, and the rate of sexual abuse was 2.7 times higher. It should be noted that the CISCAN researchers identified limitations to the study sampling methods and believed that as a result, the rate of sexual abuse was likely much higher than what was reported during family intake interviews at child welfare agencies. In general, the rate of substantiated maltreatment investigations per 1000 children was 59.8 for Indigenous children versus 11.8 for non-Indigenous children.  The CISCAN also gathered information on concerns about children’s behavior that were noted by social workers during the initial process of in-taking information on families’ situations. The behaviours that social workers noted included depression/anxiety/social withdrawal symptoms, aggression, attachment issues, developmental issues, alcohol/drug use, self-harming, and suicidality (Sinha et al., 2011). Each of these concerns was recorded more frequently for Indigenous children than non-Indigenous children. In addition, the social workers expressed concerns about the children’s caregivers, including their victimization or perpetration of domestic violence, engaging in problematic alcohol and/or drug use, having few social supports, having identified mental health issues, and having a history of being in foster care. Not surprisingly, each of these categories of concern were noted significantly more often for Indigenous caregivers than non-Indigenous caregivers.  One of the CISCAN’s main inferences was that the disproportionately high numbers of Indigenous families who were living in conditions of poverty and household overcrowding may explain the disparity between the rates of substantiated neglect among Indigenous and non-Indigenous children (Sinha et al., 2011). These socially and structurally influenced conditions may also explain why Indigenous children accounted for 48% of all Canadian children in foster   25 care in 2011, even though they comprised just 7% of Canadian children in that age group (Statistics Canada, 2013). British Columbia statistics are equally daunting, as Indigenous children accounted for 52%of children in the foster care system in 2011, but represented only 8% of all the children in the province. The CISCAN reports have been instrumental in providing an estimate of the number of Indigenous children and families who are impacted by family violence. However, the CISCAN is limited because it is based only on information that came to the attention of child protection agencies during initial intake interviews and did not include children who were already involved with the child welfare system. In addition, attempts to collect information on violence against children are further constrained by the fact that in most cases, it remains hidden and underreported (Pinheiro, 2006). It is therefore not surprising that other studies of family violence and abuse in Indigenous communities across Canada have produced highly inconsistent results. For example, estimates of the prevalence of childhood sexual abuse within Indigenous communities between 1989 and 2007 ranged from 23% to 100% of individuals sampled (Collin-Vézina et al., 2009). The 1991 Aboriginal People’s Survey found that 39.2% of respondents aged 15 and over had experienced family violence, that 24.5% had experienced sexual abuse, and that 15% had experienced sexual assault (Statistics Canada, 1991).  Despite knowledge of the high levels of violence and abuse experienced by Indigenous young people, very little understanding of the pathways that guide Indigenous people from childhood trauma to health and healing. These pathways do exist, and gaining insight into them is essential to addressing issues of childhood maltreatment among Indigenous people. For example, McEvoy and Daniluk (1995) interviewed six Indigenous women who had experienced sexual abuse and were seeking therapy. The interviews demonstrated that their feelings of shame   26 related to sexual abuse had led them to use alcohol and drugs, and that their healing journey had included the reintegration of their Indigenous cultural identity. This study highlighted the need for greater clarity about how to support the healing of Indigenous women who have experienced childhood trauma and have struggled with substance use.  Lastly, the research reviewed in the preceding paragraphs suggests that sexual abuse is a significant issue for Indigenous people, but has provided virtually no information about other forms of child maltreatment and their relationship to health outcomes over time. Addressing this knowledge gap is critically important, particularly in light of the long-term impacts of childhood maltreatment and involvement in the child welfare system. Exposure to these factors are known to have damaging effects on mental, emotional, and physical health across the life course – including vulnerability to HIV and HCV infection (Fowler, Toro, & Miles, 2009; Pilowsky & Wu, 2006; Surratt & Kurtz, 2012).  2.3 Relationship between childhood maltreatment and HIV risk among Indigenous young people in Canada Research has demonstrated that Indigenous people in Canada are overrepresented among people who have experienced childhood maltreatment as well as people living with HIV and HCV infection. However, there is a paucity of literature has addressed the association between these childhood maltreatment and HIV and HCV vulnerability among Indigenous peoples. Scientific and theoretical literature on other populations has identified childhood maltreatment as a health determinant that increases vulnerability to drug and sex-related risk behaviours that in turn increase the risk of HIV and HCV infection (Allers & Benjack, 1991; Amaro, 1995; Arriola, Louden, Doldren, & Fortenberry, 2005a; Browning & Laumann, 1997; Finkelhor & Browne, 1985; Meade, Kershaw, Hansen, & Sikkema, 2009). Further, the effect of childhood   27 maltreatment on increased vulnerability to HIV infection has proven to be extreme among populations of people who use illicit drugs (Braitstein et al., 2003; Kang, Deren, & Goldstein, 2002; Zierler et al., 1991). For example, an analysis by Braitstein et al. (2003) included 1437 adults who inject drugs in Vancouver, BC, and compared male and female participants who had been sexually abused with those who had not. The study found that men who had been sexually abused before the age of 13 years were 1.8 times as likely to share injection equipment than men who had not been sexually abused, while women who had been sexually abused were 2.8 times as likely to share injection equipment than women who had not been sexually abused. In addition, participants who had been sexually abused had a significantly higher prevalence of HIV infection than those who had not been sexually abused (25.3% vs. 19.1%, respectively). Although most studies addressing vulnerability to HIV have focused exclusively on the uniquely damaging effects of sexual abuse, some researchers have begun to explore the effects of other types of abuse. For example, a cross-sectional analysis of 701 African American adolescent women who were at high risk for HIV found that participants who had experienced both emotional and physical abuse were less likely to use condoms consistently (Brown et al., 2014). Similarly, a cross-sectional sample of 553 adults who injected drugs in Washington, DC, U.S.A., physical and emotional abuse were associated with a 4.5-fold increase in the odds for women’s risk of HIV infection (Magnus, Peterson, Opoku, & Wood, 2012). Researchers have also begun to recognize that multiple experiences of maltreatment may have a dose-response on adverse health outcomes, including HIV and HCV risk in adulthood. Dube et al. (2003) measured the effect of multiple forms of childhood abuse and neglect on the risk of illicit drug use among a sample of 8,618 adults in California, U.S.A. The authors demonstrated that each type of abuse   28 independently increased the risk of illicit drug use by 2-4 fold. When the abuse types were combined, each contributed to a graded increase in risk. As previously stated, few studies have addressed the association between childhood trauma and HIV vulnerability among Indigenous young people who use drugs. One Cedar Project-based analysis that included 543 young Indigenous people who used drugs in Vancouver and Prince George, Canada found that 48% had been sexually abused. In addition, the study reported significant bivariate associations between sexual abuse, having had a parent who attended residential school, and having been in the child welfare system (For the Cedar Project Partnership et al., 2008). The analysis also demonstrated that sexual abuse increased Cedar Project participants’ sexual vulnerability to HIV infection, which included a 49% greater likelihood of having a sexually transmitted infection; an 85% greater likelihood of having had over 20 sexual partners in their lifetime, and a 77% greater likelihood for involvement in sex work. Finally, the same analysis demonstrated that participants who had been sexually abused had a two-fold increase in likelihood of being HIV positive compared to participants who had never sexually been abused, after adjusting for demographic factors. Several studies in the United States that have included American Indian people have reported similar findings. For instance, Simoni et al. (2004) reported that 34% of 155 American Indian women in New York city had experienced sexual violence by a non-partner and 20% had experienced physical violence by a non-partner. Although the authors did not indicate how old the women were when they experienced trauma, it associated exposure to sexual and physical violence with increased injection drug use.  These epidemiological investigations have generated insight into the HIV vulnerability of Indigenous young people who use drugs, but they have been limited in that they have focused   29 solely on the effect of childhood sexual abuse; have been based only on cross-sectional data; or; involved female participants only. Further, the complex pathways by which childhood maltreatment experiences lead to the vulnerability to HIV risk behaviours and infection throughout the lives of young Indigenous people who use drugs are relatively uncharted. These knowledge gaps limit our understanding of childhood maltreatment and subsequent vulnerability to HIV risk among young Indigenous people − including the risks that arise for those who inject drugs and are involved in sex work.  2.4 Mental health and HIV vulnerability among young Indigenous people who use drugs in Canada Most research that has addressed mental health among Indigenous peoples have focused on the association between childhood trauma and psychological distress. Duran et al. (2004) carried out a cross sectional study that included 234 urban American Indian women in New Mexico, U.S.A. The results indicated that severe maltreatment of any form increased the lifetime prevalence of mood disorders (Prevalence Ratio (PR): 2.10), anxiety disorder (PR: 1.65) and post-traumatic stress disorder (PR: 3.91). However, few studies have investigated the association between childhood trauma, psychological distress, and substance use among young Indigenous people who use drugs in Canada. Such research is essential to advancing an understanding of the association between mental health and HIV vulnerability among young Indigenous people who use drugs. In particular, there is need to investigate the temporal associations between childhood maltreatment, vulnerability to HIV infection and psychological distress among young people who use drugs. Psychological distress may be referred to as “an unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope” (NCCN, 1999).   30  Indigenous authors and Elders have explained that young Indigenous young people use substances to cope with stress, which indicates that they may be self-medicating for psychological distress (Walters & Simoni, 2002). These authors have also posited that co-morbid mental health conditions and problematic substance use among Indigenous peoples are under-diagnosed and arise from unaddressed historical and lifetime trauma (Walters et al., 2002). This is highly concerning for two primary reasons. First, psychological distress and substance use are often concurrent in populations who are at high risk for HIV and HCV infection (Bell & Britton, 2014; El-Bassel et al., 1997b; Meade et al., 2009; Strehlau, Torchalla, Kathy, Schuetz, & Krausz, 2012). For example, a cross-sectional study of 343 opioid-dependent adults in 12 cities across the United States found that having clinical depression was associated with high frequency injection drug use and needle sharing (Pilowsky, Wu, Burchett, Blazer, & Ling, 2011). Second, research has found that co-morbid mental health and substance use disorders often develop as the result of complex trauma (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Schilling, Aseltine, & Gore, 2007). Some researchers are beginning to address the complex intersections of trauma, mental health, and substance use and their potentiality for exacerbating vulnerability to HIV infection. One of these, the Adverse Childhood Experiences study, was conducted among 9323 adults in California, U.S.A. It demonstrated that there was a strong graded relationship between the number of childhood maltreatments that participants had experienced, mental health symptoms, and self-reported histories of sexually transmitted infections (and subsequent increased risk for HIV infection) (Hillis, Anda, Felitti, Nordenberg, & Marchbanks, 2000).  There have been some research initiatives that have focused on Indigenous peoples and have been lead by Indigenous authors. For example, Evans-Campbell et al. (2006) explored the association between interpersonal violence, mental health and HIV vulnerability in a cross   31 sectional analysis of 112 adult American Indian women in New York City, U.S.A. The authors reported that 64.5% of the women had experienced major depression, 65.5% had experienced interpersonal violence, and 86.9% had engaged in unsafe sex. In adjusted analysis, the women who had experienced multiple victimization (at least 2 out of 3 categories of violence, including lifetime sexual assault, childhood physical abuse, or domestic violence) had significantly greater odds for ever having been depressed or dysphoric (OR: 3.19 and 2.73, respectively) and for engaging in sexual risk behaviours (OR: 10.00). Libby et al. (2005) investigated the association between childhood maltreatment and subsequent lifetime psychological distress symptoms among 3084 American Indian people aged 15-54 years in the Plains region of the United States. In multivariate analysis, the authors demonstrated that childhood physical abuse significantly increased the likelihood for depression (OR: 2.14), post-traumatic stress disorder (PTSD) (OR: 2.87), and panic disorder (OR: 2.73). Childhood sexual abuse increased the likelihood for depression (OR: 2.45), PTSD (OR: 5.30) and panic disorder (OR: 2.30), while substance use disorder was significantly associated with depression (OR: 1.85), PTSD (OR: 1.94), and panic disorder (OR: 2.18). Finally, Pearce et al. (2008) carried out a cross-sectional analysis of 543 Cedar Project participants that addressed the associations between sexual trauma, addiction, and mental health. The adjusted analyses indicated that Cedar Project participants who had been sexually abused were significantly more likely to self-report that they had been diagnosed with a mental illness (OR: 2.0) than participants who had not experienced abuse and significantly more likely to have thought about suicide (OR: 2.68) and to have attempted suicide (OR: 2.68). Several researchers have added another dimension to this body of work by addressing the suggestions of Indigenous scholars regarding the impacts of lifetime and historical trauma. For example, researchers have explored   32 the association between these traumas, mental health problems and the suppression of Indigenous cultural teachings and traditions that promote mental wellness and healing (For the Cedar Project Partnership et al., 2008; Kirmayer et al., 2003; Moniruzzaman et al., 2009; Wexler, 2006). Additionally, Whitbeck et al. (2009) reported on the prevalence and correlates of perceived historical loss among 459 Indigenous youth living on reserves in the U.S. and Canada. The research found that between 10-25% of the youth thought daily about their community’s cultural losses (i.e. land, language, traditional/spiritual ways) and losses due to alcoholism and early death in their communities. The multivariate modeling, it was revealed that the youth’s perceived losses were significantly associated with symptoms of depression (β: 0.16). However, a paucity of literature that addresses cultural strengths that support young Indigenous people’s mental health. This reflects an important gap in the literature, particularly in light of the many Indigenous cultures, spiritual traditions, and languages that have survived and clearly function to strengthen individuals’ ability to cope with stress and promote mental wellness among communities as well as individuals (Dion-Stout et al., 2001; Kirmayer et al., 2003; Korhonen & Ajunniginiq, 2006; Lavallee & Clearsky, 2006).  2.5 Trauma, resilience and HIV vulnerability among Indigenous young people in Canada As indicated in the previous section, there is a call for researchers to identify cultural factors and coping strategies that buffer the effects of historical and lifetime traumatic stressors on Indigenous people and potentially protect against substance use, mental health issues, and HIV and HCV infection (Duran & Walters, 2004; Walters et al., 2002). Such research is critical to public health interventions that aim to meaningfully address the root causes of HIV and HCV risk among young Indigenous people in Canada who use drugs and requires health researchers to find alternatives to the risk models of disease.    33 Indigenous authors have emphasized that resilience is a key cultural strength or buffer for Indigenous peoples that is inherent to their cultures and spiritual traditions (Lavallee & Clearsky, 2006) and as such, has withstood the devastation of colonization and its associated adversities (Fleming & Ledogar, 2008a; Henderson, 2008; Kirmayer et al., 2003; McIvor et al., 2009). The most accepted definition of resilience in psychological and health sciences research is positive adaptation despite adversity (Luthar, Cicchetti, & Becker, 2000). For resilience to be treated as a mental health outcome for an individual, family, or community, it must be understood to be a response to substantial risk, stress, or trauma (Luthar et al., 2000). Moreover, in order to be culturally relevant, resilience must be seen as a response motivated by personal aspirations to overcome adversity or trauma and as a health determinant that reflects access to culturally meaningful resources and as such, is highly sensitive to social and cultural ecology (Ungar, 2013). It follows that any consideration of resilience as a determinant of health for young Indigenous people in Canada must acknowledge the historical and present-day injustices that impede the full realization of resilience as well as the diminish the culturally-specific community strengths that support it (Tousignant & Sioui, 2009). Existing empirical research on resilience among Indigenous peoples in North America has demonstrated significant associations between access to Indigenous cultures, languages, and spiritual traditions and positive health outcomes such as strong family relationships, cessation of alcohol use, decreased rates of youth suicide, increased emotional wellbeing, and decreased criminal activity (Andersson & Ledogar, 2008; Chandler & LaLonde, 1998; Currie, Wild, Schopflocher, Laing, & Veugelers, 2013; Torres Stone, Whitbeck, Chen, & Johnson, 2006). For example, a unique cross-sectional analysis that involved 311 Métis youth living on-reserve in Alberta, Canada found that having pride in Métis heritage was associated with 5-fold greater   34 odds of “feeling supported” by family or community members (Andersson & Ledogar, 2008). Chandler and Lalonde’s (1998) landmark research that involved 196 Indigenous bands within the jurisdiction of 29 tribal councils in BC, Canada, demonstrated that factors associated with cultural continuity − including self-governance, band-controlled health and education initiatives, and speaking traditional languages − were associated with lower rates of suicide among Indigenous youth.  Qualitative studies have also described how young Indigenous people develop and apply cultural strengths that help them to respond to adversity in healthy ways. For example, Wexler et al. (2014) carried out qualitative research among Inupiaq youth living in a village in Alaska, U.S.A. Although many of the youth’s relationships with friends and family had been fragmented due to alcohol/drug use and their being adopted out, they had found resilience when they accessed traditional activities in their community that instilled pride in their cultural identity and formed connections with Elders.  The aforementioned research provides essential information about how to support young Indigenous people who are coping with historical losses and personal/intergenerational trauma within their communities. However, Fleming & Ledogar (2008b) identified an important gap in research on the resilience involving Indigenous people in Canada: a specific lack of understanding about how to support the health of young Indigenous people who are living in cities and may be disconnected from their home communities, languages, cultures, and spirituality. To date, there is a paucity of research that has addressed this question. Currie et al. (2013) carried out a cross-sectional analysis of 371 Indigenous adults living in Edmonton, Alberta (62.5% of whom reported illicit drug use in the previous 12 months). The results demonstrated that every 1-point increase on a pan-Indigenous enculturation scale was associated   35 with a 1.7-point decrease on an illicit drug use scale (after adjusting for socioeconomic and childhood abuse factors). In addition, Andersson & Ledogar (2008) carried out research that involved 622 Indigenous adolescents and young adults in Winnipeg, Manitoba found that participants who felt that it was important to participate in traditional cultural activities were 2.6 times as likely to score higher on an emotional competence scale and less likely to use alcohol or be involved in crimes. Although these research endeavors have generated valuable insights, they did not explicitly identify culturally-based family or community strengths that are accessible to young Indigenous people living in cities. In addition, they did not specifically address the impact that historical and lifetime traumas have had on resilience or the relationship between HIV vulnerability and resilience among young, urban Indigenous people in Canada who use drugs. 2.6 Summary of literature review The primary purpose of this literature review was to provide an overview of the literature that is relevant to the research conducted for this dissertation. It provided a summary of the available epidemiological and qualitative research on HIV and HCV vulnerability and risk, childhood maltreatment, mental health, and resilience among young, at-risk Indigenous people in Canada. In addition, the literature review highlighted studies that have addressed the complex intersections between these research dimensions and identified knowledge gaps that limit public health’s capacity to meaningfully respond to the HIV and HCV epidemics among young urban Indigenous people who use drugs in Canada. Finally, qualitative health researchers who conduct future research involving young Indigenous people who use drugs and live in cities should be aware of the complex social and cultural ecology that informs their lived experience. In addition, they must recognize and investigate adaptations and resistance to adverse circumstances.   36 Chapter 3: Methodology The candidate (M.E.P.) conducted this study within the existing research framework of the Cedar Project, a prospective cohort study involving young Indigenous people who use drugs in three cities in British Columbia (BC), Canada. Both secondary and primary data sources were used. The quantitative information was a secondary source, as the research tools were designed by study investigators and Indigenous collaborators (i.e. the Cedar Project main and nursing questionnaires) or other authors (i.e. the CTQ, SCL 90-R, and CD-RISC), and Cedar Project study staff recruited participants and carried out data collection. Completed questionnaires were entered into a database by one data entry person and managed by Cedar Project statisticians. The candidate independently carried out data cleaning, integration, and all statistical analyses. Interpretation of quantitative study findings was aided by the expertise of members of the Cedar Project Partnership. The qualitative information was a primary source, though gathered and interpreted with support and collaboration from the Cedar Project study team and members of the Cedar Project Partnership. The candidate independently funded the qualitative data collection, developed the topic guide, conducted 29 out of the 30 in-depth interviews, performed and supervised transcription, and coded and analyzed the qualitative data. This chapter describes the quantitative and qualitative study designs, sampling methods, quantitative and qualitative research instruments, data management decisions, approaches to analyses, and ethical considerations for this dissertation.  3.1 The Cedar Project methods The following section outlines the overall Cedar Project study design, sampling methods, and describes the study locations where participants were recruited.    37 3.1.1 Study design The Cedar Project is a prospective cohort study of young Indigenous people who use drugs in Vancouver, Prince George, and Chase, BC. Since 2003, the study has worked with young, at-risk Indigenous people to gather epidemiological and health information that may be used to better understand HIV and Hepatitis C (HCV) risk and other health outcomes. The primary goal of the study is to provide a robust scientific evidence base that is informed and governed by Indigenous people in order to effectively lobby for their youth.  Eligibility criteria for the Cedar Project included self-identifying as a descendant of the First Nations Peoples of North America (including Indigenous, Aboriginal, Métis, First Nations, Inuit and Status and non-Status Indians), being between 14 and 30 years old, and having smoked or injected illicit drugs (other than marijuana) in the month before enrolment. Drug use was confirmed using saliva screens (Oral-screen, Avitar Onsite Diagnostics). Participants were recruited with the help of health care providers and street outreach, and by word of mouth. At their baseline and follow-up visits (scheduled at 6-month intervals), participants were taken through the process of informed consent, whereby we explained the legal limitations of confidentiality in cases where the participant disclosed awareness of a child under the age of 19 years old who was being harmed, and the reportability of HIV, hepatitis B, C, and tuberculosis.  Participants then completed a structured questionnaire administered privately by trained Indigenous and non-Indigenous staff that focused on historical and lifetime experiences and behaviours. Staff nurses then administered health questionnaires regarding clinical symptoms, and provided pre-and post-test counseling for drawing venous blood samples that were tested for HIV and HCV antibodies. Although not required, participants were requested and encouraged to return to receive their test results. Study staff worked actively with participants to secure any   38 physical, emotional, spiritual, or mental supports they needed. Each participant received a $25 stipend for their time.  Since the inception of the Cedar Project, the study team has worked to assure that the study offices are culturally-safe environments for participants. All staff members are knowledgeable about the historical injustices of colonization and the residential school and child welfare systems in Canada and their effects on the health and wellbeing of Indigenous families and communities. Every interaction with participants therefore comes from this knowledgeable perspective. Time is taken with each participant to get to know them and to build a trust-based relationship. The participants’ needs and safety are prioritized and they are routinely reminded that they are in control of whether they share their information with the Cedar Project or not. We also aim to create safety within the study offices themselves, by ensuring that each is a cheerful, non-judgmental, and police-free space. Participants are welcome to use the telephone, the internet, and have access to coffee and snacks. In addition, the participants are invited to attend special annual events including Christmas dinners and memorials for participants who have passed away. Optimized follow-up of participants has therefore been achieved through the prioritization of cultural safety and because of the vigilance of the study team in keeping in touch with participants via outreach on the street level and personal level (e.g. sending out birthday and Christmas cards). 3.1.2 Sampling methods and study locations In 2006, the Census of Canada estimated population of Indigenous people under age 34 years in BC was 82,230, of whom 74% were living off-reserve (BC Stats, 2006). Cedar Project participants were recruited non-randomly in each of the study locations through referral by health care providers, community outreach, and by word of mouth. Attaining a probabilistic   39 sample for this population was not available due to young Indigenous people who use drugs being mostly hidden and marginalized from mainstream society. In addition, it is difficult to assess how many young Indigenous people were eligible but chose not to participate in this study. This potentiality increases the uncertainty of our results. Nevertheless, the Cedar Project research team includes members who are highly experienced and connected to the community, and went to great lengths to recruit street-involved young Indigenous people who use drugs and follow-up on participants in each of the three study locations. Vancouver The city of Vancouver is located on the unceded traditional territory of the Musqueam First Nation. Located within the catchment of the Vancouver Coastal Health Authority, the city is the largest metropolitan centre in BC, with an economy based primarily in industrial development, international port trading, and technology. According to the 2006 Statistics Canada Census, 2.4% of the population within the Vancouver Coastal Health Authority service area were Indigenous peoples (n=40,310) (Milligan, 2010b).  Since the mid-1980s, Vancouver has been the epicentre of HIV and HCV infections in Canada. The Downtown East Side (DTES) neighbourhood in particular was overwhelmed with the epidemics in the 1990s, as the number of people there struggling with severe addiction, psychological distress, and poverty were in the many thousands (Adilman & Kliewer, 2000). There are an estimated 18,000 residents of the DTES, of whom 10% identify as being Indigenous people (City of Vancouver, 2012). In 2003, an analysis published as part of the Vancouver Injection Drug User Study (VIDUS) demonstrated that among individuals who injected drugs in the DTES, Indigenous people were becoming HIV positive at twice the rate of non-Indigenous people (Craib et al., 2003). Due to concerted province-wide harm reduction, the expansion of   40 highly active antiretroviral therapy, and social justice efforts, the dual epidemics of HIV and HCV have been declining in BC (BC Centre for Disease Control, 2013; Grebely et al., 2014; Hogg et al., 2013). However, 2012 data revealed that Vancouver continued to have the highest incidence of HIV infections in BC (19.1 per 100,000) and Indigenous people living in Vancouver continue to be overrepresented among new HIV infections (BC Centre for Disease Control, 2013). The Cedar Project study office opened in the DTES in 2003, and as of 2012 had enrolled 369 participants. The average age of Vancouver participants at baseline was 23.9 years (standard deviation (SD): 3.6 years), 51% were female, and 61.5% had injected drugs at least once before they entered the study. Prince George The city of Prince George is located on the unceded traditional territory of the Lheidli T’enneh First Nation. The 2006 Statistics Canada Census estimated that Indigenous peoples comprised 11% (n=8,855) of the population of Prince George and 17.5% of the population of the Northern Health Authority service catchment (Milligan, 2010a). The city is the largest in northern BC, with an economy based on services, logging, and mining. Partly due to being a centre point along two major highways for transportation of materials from resource extraction industries, Prince George has one of the highest violent crime rates in Canada and is home to multiple gangs involved in drug trafficking and sex work (Brennan, 2012). In 2002, Indigenous HIV/AIDS service organizations and public health practitioners argued that they were witnessing a simmering epidemic of HIV and HCV infections in the north that seemed to be disproportionately impacting young Indigenous people who used drugs. The Cedar Project was therefore invited to open a storefront office in downtown Prince George in 2003 in order to provide an epidemiological evidence base to lobby for increased harm reduction and prevention   41 resources in the community. In 2012, the BC Centre for Disease Control reported that the Northern Health Authority had the second highest HIV incidence in the province (5.5 per 100,000), and that Indigenous people who use drugs were overrepresented among those newly diagnosed (BC Centre for Disease Control, 2013). As of 2012, the Prince George study office had enrolled 336 participants, of whom the mean age at baseline was 22.7 years (SD: 4.3 years), 47.9% were female, and 51.2% had ever injected drugs before their enrolment interview.  Chase Chase is a rural community of 2,400 people located within the unceded traditional territory of Secwepemc Nation, in the south-western region of BC. Chase is located 45 km outside the mid-sized city of Kamloops, 50 km from the township of Salmon Arm, and within close proximity to the reserves of the Neskonlith Indian Band and Adams Lake Indian Band. The village of Chase has historically been based on the economy of forestry and tourism. The 2006 Statistics Canada Census estimated that Indigenous peoples comprised 11% (n=265) of the population of Chase (Statistics Canada, 2007), however community members have informed us that most Indigenous peoples live and travel frequently between surrounding First Nation communities and Kamloops and Salmon Arm. Chase and surrounding areas are served by the Interior Health Authority. In 2012, the Interior Health Authority reported that HIV incidence in the Interior region was well below the provincial rate (1.5 per 100,000 vs. 6.5 per 100,000, respectively), however incidence of HCV infection was above the rate for the province (43.6 per 100,00 vs. 42.1 per 100,000, respectively) (Interior Health Authority, 2012). Although no ethnicity information was available for these statistics, Secwepemc leadership have been deeply concerned about their young people who were using drugs and their vulnerability to infectious diseases. In 2011, the Cedar Project was therefore invited by the Shuswap Nation Tribal Council to open a study office in downtown Chase and to access surrounding areas   42 with a mobile van study unit. As of 2012, 88 participants were enrolled, among whom the mean age was 21 years old (SD: 4.9 years) and  49% were female. As of 2012, none of the Cedar Project participants in Chase had injected drugs before their baseline interview.  3.2 Dissertation methods The following section outlines the multidisciplinary (qualitative and quantitative) methodological approaches that were undertaken to complete this dissertation. 3.2.1 Qualitative setting and participants The qualitative portion of this study was an adjunct to the larger Cedar Project research study and therefore participants were recruited from and interviewed within the offices of each of the three study locations.  This qualitative study involved 30 young Indigenous people who were current participants in the Cedar Project study. Participants were eligible to participate in this study if they were returning to the Cedar Project study offices for a follow-up interview or had been newly recruited into the study and completed a Childhood Trauma Questionnaire (CTQ). We chose the requirement of having completed the CTQ so that we could use its results to triangulate our qualitative analysis and assess whether the richness of that information was enhanced by the CTQ. Participants were not required to have experienced childhood maltreatment because we had initially sought to compare those who had and had not experienced it and to identify any themes that emerged as a result of the comparison. Nevertheless, as the collection of qualitative and quantitative information proceeded, it became evident that all of the participants had experienced childhood maltreatment with the exception of one, a male participant who reported that he had no traumatic experiences in both the CTQ and his in-depth interview.    43 Purposive sampling was used to enroll 30 Cedar Project participants. This approach is considered acceptable because of the exploratory nature of our qualitative inquiry and because our purpose was to confirm patterns and establish the existence of variability in the experience of childhood maltreatment and subsequent HIV and HCV vulnerability among young Indigenous people who use drugs (Schensul, Schensul, & LeCompte, 1999). The qualitative researcher (M.E.P.) worked with Cedar Project study staff (interviewers and coordinators) to establish the sampling method by which they were requested to approach Cedar Project participants who: a) had completed a CTQ, and; b) were open to the idea of having a long conversation with a female researcher about their lives. Cedar Project participants who met the qualitative study enrolment criteria were approached by study staff and asked if they were interested in participating in an in-depth, open-ended interview. Cedar Project staff explained to the participants that the interview would involve conversations about family history and, if relevant, the context in which childhood maltreatment occurred. Study staff also informed participants that they would receive a $20 stipend (in addition to the stipend received for their participation in the Cedar Project) for their time and transportation costs. Vancouver-based participants who were interested in the in-depth interview gave their phone number to the staff and understood that they would be contacted by a researcher (M.E.P.) to arrange the interview. The qualitative researcher then contacted the participants and arranged a time for the interview. For participants living in Prince George and Chase, the local Cedar Project study staff arranged the interview times and the researcher (M.E.P.) traveled to the study locations to carry out the interviews. All of the in-depth interviews took place between October 2011 and June 2013. Nearly all of the interviews were carried out in private offices at Cedar Project study sites; two took place in private meeting rooms at local service organizations. Interviews were typically booked in the evenings and on   44 weekends when the Cedar Project locations were closed. The first 2 interviews were facilitated by Nancy Laliberté (Métis ancestry), an experienced qualitative interviewer for the Cedar Project, who also trained M.E.P.. The rest of the interviews were conducted exclusively by M.E.P, with the exception of one interview with a Prince George participant. The participant was leaving town and eager to do the interview immediately, so it was conducted solely by Vicky Thomas (Wuikinuxv Nation), the Cedar Project Study Coordinator and an experienced interviewer. Of the 30 participants who participated in this study, 18 (60%) were women and 12 (40%) were men. Seventeen participants (56.6%) were based in Vancouver, 11 (36.6%) were based in Prince George, and two (6.6%) were based in Chase. The participants’ median age was 32 at the time of their in-depth interview, (Range: 21-39). In total, five participants (16.6%) were HIV positive, and 12 (40%) participants were HCV positive. Eighteen participants (60%) had ever used injection drugs. 3.2.2 Qualitative data collection  We decided to use the in-depth interview approach because so little is known regarding the lived experiences of childhood maltreatment and subsequent pathways to HIV and HCV vulnerability among young Indigenous people who use drugs. In-depth interviews are exploratory and therefore allow the researcher to be flexible in covering the topic of interest in addition to any new topics that might arise during the interviews (Schensul et al., 1999). Written informed consent was obtained prior to the interview in all cases and the consent form emphasized the limitations to confidentiality that arise when it is determined that child maltreatment is currently ongoing. The interviews were 45 minutes to 2 hours in length in order to give participants enough time to share their stories. Interviews relied on a loosely structured   45 topic guide that allowed participants to contextualize any experiences of childhood maltreatment, substance use, and HIV and HCV risk within temporal or causal sequences of events, individuals, and environments. We believe this approach was appropriate, as researchers have clarified that young Indigenous people often use narratives to bridge together various moments of their lives (Brant Castellano, 2000; Tousignant & Sioui, 2009).  The in-depth topic guide covered circumstances of childhood and adulthood, emphasizing participants’ recollections of childhood experiences and emotional responses, family relationships, transitions into risk behaviours such as drug use and sex work involvement, intimate relationships, mental health issues, and sources of strength. The guide was followed loosely however the qualitative researcher (M.E.P.) prepared extensively prior to the interviews and memorized a set of general questions to guide the interview before they began. This approach also helped the interviewer to be reflexive and allowed participant’s experiences to direct the interview process. The interviews were audio recorded using a digital recording device. With the aim of listening to narratives of experiences, participants were encouraged to ‘start at the beginning’ of their life story, but we did not enforce a set timeline because we wanted participants to articulate their complex and interwoven memories in a narrative that felt natural. The interviewer probed on various topics to aid with the flow and detail of the interviews and to address difficult subjects that participants did not bring up. For example, after the first two interviews, probes were included to recall their emotional responses to life events. 3.2.3 Qualitative data analysis We chose to apply an interpretive thematic approach to the analysis of the qualitative data (Starks & Trinidad, 2007). This method of analysis allowed us to engage as witnesses of the accounts of childhood maltreatment and associated processes that prompted stress-coping   46 responses among Cedar Project participants. Stress-coping in this study refers to both the risk and protective strategies that Cedar Project participants used in order to adapt to – and survive – emotional, physical, mental, and spiritual stresses related to historical and lifetime traumas. Each participant was given a pseudonym in the analysis to protect their confidentiality. Extensive field notes were written after each interview in order to record observations that may not have been captured in the audio recording, develop new questions, and generate theoretical insights. Each participant’s audio interview was transcribed verbatim and read repeatedly to identify recurring and contradictory patterns and correlations with theory and literature. Codes were created by categorizing specific statements into groups of meaning that represented subjects of interest, exploring taken for granted assumptions, and paying special attention to the descriptions of what participants experienced and how they experienced it. The strategy of “constant comparison” (LeCompte & Schensul, 1999, p. 75) was used in the reintegration of the data, wherein central themes and relationships were drawn across all of the participants’ narratives (Starks & Trinidad, 2007). The data were organized and coded using NVivo 10, a qualitative software package (QSR International Pty Ltd., 2012). Words, phrases, and quotes that illustrated the concepts, patterns, and themes were drawn from the transcripts. The analysis was continually evaluated during frequent discussions with study staff thesis committee members, and the researcher’s mentors from the Cedar Project Partnership. This was done so that the researcher could remain vigilant about any preexisting thoughts and beliefs, for hypotheses development, and to strengthen the credibility of the analysis (Starks & Trinidad, 2007). In addition, cross comparisons with existing Cedar Project studies and the triangulation of quantitative and qualitative data enriched the rigor and trustworthiness of the analysis. The coding scheme and analysis were presented to the Cedar Project Partnership on December 6, 2012, and members provided critical feedback and   47 consensus about the themes to be interpreted and the associated recommendations. In the writing phase of the study the researcher aimed to compose a story that captured the most important elements of participants’ lived experiences (Starks & Trinidad, 2007). Extensive notes and memos were taken to document all decisions and insights at each stage of the research and to establish an audit trail.  Combining epidemiologic and qualitative methods is a proven standard in conducting research involving people who use drugs (Bourgois, 2002; Maher, 2002). As previously mentioned, we aimed to use an interdisciplinary approach by triangulating the quantitative data generated from the CTQ with the information participants shared in their in-depth interviews. Following Denzin (1971), we use the term triangulation to mean both data triangulation (use of a variety of data sources within a study) and methodologic triangulation (use of multiple methods within a study). Methodologic triangulation uses both qualitative and quantitative methods to study similar questions. Specifically, we sought to use qualitative observation to validate the quantitative patterns of maltreatment that emerge in the CTQ, and to generate new hypotheses that may be subsequently tested using quantitative data. 3.2.4 Quantitative data collection instruments Multiple quantitative tools were utilized in this research and were integrated to meet study objectives and test hypotheses. The following are descriptions of the study instruments, decisions regarding variable coding, and how missing data were handled.  3.2.4.1 The Cedar Project questionnaire The Cedar Project questionnaire was administered by trained Indigenous and non-Indigenous interviewers and nurses in each study location for participants’ baseline enrolment visit and at 6-month follow-up intervals. The questionnaire assessed sociodemographic   48 characteristics, drug use patterns and risk behaviours, sexual practices, service utilization, and experiences involving violence. In addition, a separate nursing questionnaire asked clinical questions to determine participants’ general health status, including whether they had symptoms of sexually transmitted infections and tuberculosis or were on prescribed medications. The nurses also drew blood samples for HIV and Hepatitis C testing and carried out pre-and post-test counseling  with the participants. Variables were chosen from the Cedar Project Questionnaire based on their theoretical and empirical importance to the study hypotheses. The cut-point for the longitudinal data in this research was November 2012.  Time-invariant factors  The time-invariant (i.e. asked only once at baseline) demographic and historical variables that were included this study included sex (male vs. female), study location (Chase, Prince George, Vancouver), having at least one parent who attended residential school (no vs. yes, no vs. unsure), having been taken away from biological parents and placed in foster care (no vs. yes), sexual identity (gay/lesbian/bi-sexual/transgender/queer (GLBTQ) vs. straight) and education level (less than high school vs. high school graduate). Other time-invariant variables that were treated as potentially protective independent study variables pertained to the cultural environment participants grew up in and included how much their families lived by traditional culture (never/rarely vs. often/always) and how often their families spoke traditional languages at home (never/rarely vs. often/always). Finally, a time invariant study variable determined whether participants spoke their traditional language (no vs. a little bit vs. yes). Living by traditional culture was defined as living according to values that are inherent to customary Indigenous ways of life and taught by Elders. The values included humility, honesty, love, respect, loyalty, remembering where you are from, and putting family   49 first. These variables were defined by Earl Henderson (Métis and Cree Heritage) and Violet Bozoki (Lheidli T’enneh Nation) who are Indigenous Elders, traditional knowledge holders, and members of the Cedar Project Partnership.  Time-varying factors Time-varying potential confounders were longitudinal variables that may have changed in the 6 months between follow-up interviews and included age as well as relationship status (single vs. in a relationship). Time varying independent variables that measured cultural activity in the past 6 months and were hypothesized as being potentially protective included frequency of living by traditional culture (never/rarely vs. often/always), and having participated in any traditional ceremonies (never/rarely vs. often/always). Participating in traditional ceremonies was defined as having attended or taken part in ceremonies such as: potlatch, feast, fast, burning ceremony, washing ceremony, naming ceremony, big/smoke house, rights of passage, smudge, dances (pow-wow, Ghost dance, Chicken dance, Round dance, Sun dance), or any other traditional Indigenous ceremony. Other potentially protective longitudinal study variables were having accessed alcohol or drug treatment (no vs. yes), having accessed counseling (no vs. yes), and having tried to quit using drugs (no vs. yes). Potential risk factors that applied to all participants in the context of the previous six months included having slept on the streets for more than three consecutive nights (no vs. yes), frequency of having smoked crack (less than daily vs. daily or more), any injection drug use (no vs. yes), and HIV and HCV serostatus (negative vs. positive). Drinking-related factors were assessed in the subset of participants who had drank alcohol in the previous 6 months and included binge drinking (no vs. yes) and blackouts from drinking (no vs. yes). Binge drinking was defined as going on runs or binges and drinking more than usual. Sexual risk-related outcomes were a subset to participants who had sex   50 in the previous 6 months and included involvement in sex work (no vs. yes), consistency of condom use with regular sexual partners (always vs. not always), consistency of condom use with casual sexual partners (always vs. not always), sexual assault (no vs. yes), and any sexually transmitted infection (no vs. yes). Regular sexual partners were defined as partners with whom participants had had sexual relationships lasting 3 months or more, and casual sexual partners were defined as partners with whom participants had had sexual relationships lasting less than three months. Sexually transmitted infections were self-reported in the nursing questionnaire and may have included chlamydia, genital wards, gonorrhea, herpes, syphilis, or others.   3.2.4.2 Childhood Trauma Questionnaire Beginning in 2011, Cedar Project study staff offered participants the option to complete the Childhood Trauma Questionnaire (CTQ). The CTQ is a widely used retrospective and self-reported 28-item inventory that measures five types of childhood maltreatment: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect (Bernstein & Fink, 1998). Validation studies of the CTQ have demonstrated that it is a brief, reliable and valid instrument for screening histories of maltreatment as well as identifying minimization and denial (Bernstein & Fink, 1998).  Each type of maltreatment was measured with 5 items that were asked within the context of “when you were growing up”. Answers were endorsed using a 5-point Likert-type scale according to the frequency the experiences occurred. Scale options were: Never True [1], Rarely True [2], Sometimes True [3], Often True [4], and Very Often True [5]. The Minimization/Denial Scale is an additional 3 items in the CTQ and is used to detect false-negative reports of childhood trauma. In this study 19.5% (n=52) participants had low minimization/denial, 9% (n=24) had moderate minimization/denial, 1.9% (n=5) had high minimization/denial, and the   51 remaining 69.6% (n=185) had zero scores for minimization/denial. It should be noted that CTQ authors Bernstien & Fink recommend that results showing any level of minimization/denial should be treated with caution, but do not recommend that participants with minimization/denial be removed from analyses (1998).  Item scores for each CTQ subscale may be summed into a total score ranging between 5 and 25 in order to quantify the severity, frequency, and duration of maltreatment. In addition, Bernstein & Fink have suggested four pre-set thresholds to categorize the severity of childhood maltreatment experiences: None, Low, Moderate, and Severe. Previous studies using the CTQ have combined the categories of the maltreatment subscales in order to address the unbalanced response patterns that often arise in marginalized or drug using populations (Duran et al., 2004; Medrano, Hatch, Zule, & Desmond, 2002; Stoltz et al., 2007). Floor and ceiling effects (Hessling, Schmidt, & Traxel, 2004; Hessling, Traxel, & Schmidt, 2004) were observed for the maltreatment subscales in the Cedar Project sample. We therefore transformed the subscales into variables composed of three categories for levels of maltreatment – none (0), low/moderate (1), and severe (2) – and treated the subscales as continuous variables in the analyses. The odds ratio for the maltreatment subscales may therefore be interpreted as the likelihood of an outcome occurring for each one-level increase in severity (i.e. the increased likelihood of an outcome in the ‘low/moderate’ level vs. the ‘none’ level, and in the ‘severe’ level vs. the ‘none’ level of maltreatment).  Previous CTQ-based research has also examined the impact of multiple types of maltreatment by characterizing the impact of the total ‘dose’ of exposure to childhood maltreatment on health outcomes and creating a maltreatment summary score (Rodgers et al., 2004). Consequently, an additional maltreatment summary score variable was created for the   52 Cedar Project sample by first categorizing participants as “maltreated” or “not maltreated” on each of the five CTQ sub-scales (based on the clinical threshold scores), then summing the number of thresholds that were exceeded. The maltreatment summary score variable ranged from zero to five and was treated as a continuous variable. The odds ratio for this variable could then be interpreted as the likelihood of an outcome occurring for each incremental increase in the maltreatment summary score.  Because the CTQ is a retrospective inventory, the Cedar Project participants only completed it once. After giving their consent to answering the CTQ and receiving instructions on how to answer it, participants took approximately five minutes to complete it. The CTQ was self-administered unless participants requested assistance. Participants were given a stipend ($10) for their participation and Cedar study staff made referrals to counseling  or other services if they were requested.  Validation studies of the CTQ have demonstrated that it provides brief, reliable and valid screening for histories of maltreatment (Bernstein & Fink, 1998). The CTQ has demonstrated very good internal consistency reliability according to Cronbach’s alpha, and has good test-retest reliability suggesting that it is stable over time in relatively uncontrolled settings (Bernstein & Fink, 1998). The CTQ has been validated among adults who use drugs (Thombs, Lewis, Bernstein, Medrano, & Hatch, 2007), and homeless young people in Canada (of whom 12% identified as Aboriginal people) (Forde, Baron, Scher, & Stein, 2012). Although the CTQ has not yet been validated exclusively for Indigenous people, it has been utilized to measure childhood maltreatment in a study of American Indian Women in New Mexico, USA (Duran et al., 2004), and among men and women in seven different Native American tribes in the United States (Koss, 2003).    53 3.2.4.3 Symptom Checklist-90 Revised Since 2010, the Symptom Checklist-90-R (SCL-90-R) has been administered at 6-month intervals together with the main Cedar Project Questionnaire follow-up interviews. The SCL-90-R is a 90-item self-reported symptom inventory that has been designed to measure the intensity or severity of nine dimensions of psychological distress symptoms as well as seven additional clinical items (Derogatis, 1994). The psychological distress dimensions are somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. After participants gave consent and received instructions on how to answer the SCL-90-R, they took between 12 and 20 minutes to complete the questionnaire. Cedar study staff made referrals to health and social service providers if they were requested. Each of the 90 items in the SCL-90-R questionnaire were scored on a five-point Likert scale that quantified how distressed participants were by their symptoms in the past three months: Not at all [0], A little bit [1], Moderately [2], Quite a bit [3], and Extremely [4]. The raw scores for each dimension were calculated by summing the values of the item responses, then dividing that sum by the number of endorsed items in that dimension. In addition, each participant’s SCL-90-R score was transformed into an average Global Severity Index (GSI), providing a single average measure that represents overall degree of psychological distress. The GSI is computed by summing the scores on the nine symptom dimensions and the additional clinical items, then dividing that sum by the total number of endorsed responses. Higher scores for the GSI indicate a higher level of overall psychological distress.  The SCL-90-R has demonstrated good internal consistency and reliability according to Cronbach’s alpha in addition to satisfactory test-retest reliability (Derogatis, 1994). The SCL-90-  54 R has been validated in multiple studies including research with adults accessing treatment for drug and alcohol dependency in the U.S. (Kleinman et al., 1990) and young people who had experienced childhood phsycial and sexual abuse and been in foster care in Missouri, U.S. (Williamson, Borduin, & Howe, 1991). The GSI is considered to be the best single score of psychological distress (Derogatis, 1994) and has been used successfully in studies that measured psychological distress among people who have experienced childhood maltreatment and people who use drugs (Dobkin, De, Paraherakis, & Gill, 2002; Fridell & Hesse, 2006; Gold, Lucenko, Elhai, Swingle, & Sellers, 1999; Kidorf et al., 2010). Although the SCL-90-R has not been validated specifically for Indigenous populations, it has been used to successfully estimate psychological distress symptoms, general severity of distress, and risk factors among a sample of Aboriginal adolescents in Taiwan (Yen, Hsu, Liu, Huang, & Yang, 2006) and to assess psychological distress and suicidality among Native American youth in New Mexico, U.S.A. (Howard-Pitney, LaFrambroise, Basil, September, & Johnson, 1992). The GSI was therefore the main outcome variable we used for the analysis of psychological distress.  3.2.4.4 Connor-Davidson Resilience Checklist  Since 2011, the Connor-Davidson Resilience Scale (CD-RISC) has been administered at 6-month intervals, coinciding with the main Cedar Project Questionnaire follow-up interviews. The CD-RISC is a 25-item self-administered scale designed to clinically measure the ability to cope with stress (2004, p. 196). The scale authors broadly defined resilience as “personal qualities that enable one to thrive in the face of adversity” (Connor & Davidson, 2003, p. 76). The scale consists of five factors: 1) personal competence, high standards, and tenacity; 2) the trust, tolerance, and strengthening effects of stress; 3) positive acceptance of change and secure relationships; 4) control, and; 5) spiritual influences. The CD-RISC statements on the scale are   55 endorsed by response options on a five-point Likert scale : Not true at all [0], Rarely true [1], Sometimes true [2], Often true [3], and True nearly all the time [4]. The statements are intended to reflect participants’ resilience over the previous three months. If participants had not experienced the situation described by a statement in the past three months they were asked to consider how they would have responded if that situation had arisen (e.g. an opportunity to realize that “coping with stress strengthens”) (Connor & Davidson, 2003). Overall scores were computed by summing all responses and therefore ranged between 0 and 100, with higher scores indicating greater resilience. The questionnaire was self-administered, unless participants requested assistance from the study staff. After consenting to participate in the study and receiving instructions on how to answer the CD-RISC, the questionnaire took 5-10 minutes to complete.  The CD-RISC has had very good internal consistency and reliability according to Cronbach’s alpha and good test-retest reliability (Connor & Davidson, 2003, p. 76). Validation of the CD-RISC has been tested in multiple studies, including research involving young adults seeking treatment for anxiety related to childhood maltreatment (Connor & Davidson, 2003, 2010). The psychometric properties of the CD-RISC were also examined and validated in a community sample of elderly Native Americans from the south-eastern U.S. (Connor & Davidson, 2003; Windle, Bennett, & Noyes, 2011). Further, the CD-RISC has been successfully used to explore the relationship between resilience and psychological distress among homeless youth (9% of whom were of Aboriginal ethnicity) in Hamilton, Canada (Simon et al., 2009), and to examine the association between resilience and improved health outcomes among women living with HIV in Cook County, U.S. (Goins, Gregg, & Fiske, 2012).    56 3.2.5 Quantitative data analysis  The following is a general outline of the steps taken for each quantitative analysis in Chapters 6, 7, and 8:  1. Descriptive statistics were used to assess the frequencies and distributions of the scores associated with each of the psychometric scales. For categorical data, frequencies were tabulated by historical and demographic variables including sex, and chi-square tests estimated the significance of differences. For continuous data, means and standard deviations were calculated, with t-tests and one-way ANOVA to determine significant differences between historical and demographic variables, and between men and women. Robust t-tests were used when Levene’s test established that there were unequal variances. Two-sided p-values were used to assess the statistical significance of observed differences.  2. The construct validity of the CTQ, SCL-90-R, and CD-RISC was examined using first and second order Confirmatory Factor Analyses (CFA) using Mplus software (Muthén & Muthén, 2008-2012). The first order CFA for each scale was carried out according to the scale author’s hypothesized model that involved loading each scale item onto the latent variables that the scale is intended to measure. The second order CFA included paths between the first order factors and the broad, higher order factor of the questionnaire (i.e. childhood trauma, psychological distress, and resilience). As suggested by Hu & Bentler (1998, 1999), multiple indexes were used to evaluate the goodness of fit of the CFA models, including the chi-square and measures of approximate fit including the Comparative Fit Index (CFI), the Tucker Lewis Index (TLI), the root mean square error of approximation (RMSEA). Cronbach’s alpha and the Construct Reliability Score (CRS)   57 were also calculated. CFI and the TLI values above 0.90 indicate a good fit, but over 0.95 is optimal. An RMESA of less than 0.06 is ideal.  3. Bivariate Pearson’s correlations were carried out between the variables within each scale and between the variables between each scale. Two-sided p-values measured the strength of association of the correlations.  4. For only the scales that included repeated measures (i.e. the SCL-90-R and the CD-RISC), descriptive linear mixed effects (LME) models for the trend of the mean outcome (i.e. the GSI or the mean CD-RISC score) were fitted where the elapsed time from baseline to each visit was included as an independent variable and a random statement was included to account for initial differences between individuals. Separate LME models estimated the effect of risk factors on the mean change in the study outcomes over three follow-ups with participants.  5. Longitudinal analyses were carried out using generalized linear mixed effects models (GLMM) (Chapter 6) and linear mixed effects models (LME) (Chapters 7 and 8). The GLMM models were fit by the adaptive Gaussian Hermite approximation with using a logit link to account for the binomial distribution of the study outcomes. Each model selection was based on Bayesian Information Criteria (BIC), which allowed a choice to be made between a fixed or random effect handling of the study variables. Unadjusted associations between study variables with the dependent variables that were significant at the p<0.100 level were further tested in adjusted (multivariate) models that controlled for confounders. Confounders specific to each model were chosen because of their empirical importance (i.e. significant when associated with the study variable and the dependent variable at the p<0.200 level). Potential confounders that were empirically tested in each   58 analysis included sexual identity, having a parent who had attended residential school, ever having been in foster care, location, relationship status, education level. For only Chapters 7 and 8, the CTQ subscales were also tested for potential confounding. Sex was included in each multivariable model that included all participants (i.e. was not stratified by sex). Time-varying age was included in every analysis because of its potential importance as a confounder relative to a time induced cohort effect adjustment in this study, as is recommended for longitudinal studies (Korn, Graubard, & Midthune, 1997). R statistical software Version 2.15.0 with the lme4 (Bates, Maechler, Bolker, & Walker, 2014) package was used for all GLMM and LME analyses (The R Foundation for Statistical Computing, 2012). 3.2.6 Handling missing data As with most longitudinal studies and research involving marginalized populations, it was essential in the management and analyses of data to address missing data. In this study, participants were considered lost to follow-up if they had not returned for a follow-up interview after their baseline enrolment questionnaire. Of the participants who were recruited between September 2003 and November 2012 (n=793), 81% had returned for at least one visit during the observation period. The analyses in this research was therefore based on conditional inference of those participants who were not lost to follow-up. In a sensitivity analysis, there were no significant differences in the mean age (p=0.220), sex (p=0.446), history of childhood sexual abuse (p=0.390), or history of injection drug use (p=0.262, Vancouver and Prince George participants only) for participants who were lost to follow-up compared to those who were not lost to follow-up.   59 In addition, each quantitative study in this research project had missing data. Scale questionnaires that contained more than a pre-determined threshold of missing data (set by the scale authors) were excluded from analyses; these were: 10.7% for the CTQ, 20% for the SCL-90-R, and 16% for the CD-RISC. Consequently: the data from 23 participants were removed from the CTQ study (Chapter 6); 10 participants were removed from the SCL-90-R study (Chapter 7), and; and one participant was removed from the CD-RISC study (Chapter 8). Missing data within the CTQ maltreatment subscales ranged from 2.3% to 4.1%. Missing data within the SCL-90-R dimensions ranged from 0.01% to 1.2% of observations. Finally, missing data for the CD-RISC factors ranged from 0.06% to 1.9% of observations. Longitudinal variables from the Cedar Project Questionnaires also had missing data, ranging from 1.2% of observations to 16% of observations between 2003 and 2012. After careful evaluation and recording of missing responses, it was determined that most of the missing data was due to the sensitive nature of the questions being asked of the participants. Variables with greater than 10% missing were generally excluded, however some critical outcomes for health program planning, such as having tried to quit drugs in the previous 6 months (16% missing observations), were included in the analyses. Overall, analyses did not contain more than 20% missing observations. Mplus handles missing data via full information maximum likelihood method and therefore all cases were included in the CFA of the psychometric instruments. R software, specifically the lme4 package that was utilized for all longitudinal analyses in this study, automatically uses the maximum likelihood estimation method for random missing data within outcome variables and therefore will produce results that are optimal (Bates, 2014). To-date, there are no statistical packages other than Mplus that can handle missingness among predictor variables. Despite this limitation for missing data in predictor variables, the maximum   60 likelihood method used by the R lme4 package is preferable to other approaches to missing data, such as multiple imputation, for its efficiency, consistency, and certainty (Allison, 2012).  3.3 Ethical considerations Since the inception of the study, the Cedar Project has been community-driven, multidisciplinary research that responds to the continuing crisis of HIV and HCV infection and contributes toward the health and healing of young Indigenous people who use drugs. The Cedar Project Partnership, an independent body of Indigenous community knowledge holders, health and social services experts, researchers and elected leaders, governs the entire research process. The Partnership members include individuals from Vancouver Native Health Society, the Red Road HIV/AIDS Network, Canadian Aboriginal AIDS Network, Carrier Sekani Family Services, Positive Living North, the Prince George Native Friendship Centre, All Nations Hope, Splatsin Secwepemc Nation, Neskonlith Indian Band and Adams Lake Indian Band. In addition we are honoured by the continued contributions of wisdom support from Elders Violet Bozoki (Lheidli T’enneh Nation) and Earl Henderson (Métis and Cree Heritage). The primary purposes of the Partnership are to provide governance, protection, leadership and support for the Cedar Project, and to confirm that the self-determining principles of OCAP (Ownership, Control, Access and Possession) are followed. Cedar Project adherence to OCAP principles ensures that: 1) the jurisdiction over all facets of Cedar Project knowledge/data/information that is gathered in Vancouver, Prince George, and Chase rests with the Cedar Project Partnership; 2) the relevance of Cedar Project research to Indigenous communities – including research questions, objectives, methods, and analyses –is determined by the Cedar Project Partnership; 3) the sharing of information gained from the Cedar Project evidence base is directed by the Cedar Project Partnership – including all knowledge translation activities, academic publications, and media/   61 communications, and; 4) a stewardship model is used whereby the Cedar Project database is housed on servers that are protected by firewalls within the Providence Healthcare Research Institute (Vancouver, BC). This support is an in-kind contribution for maintaining the database, however the Cedar Project Partnership regulates the right to access Cedar Project information. The Partnership meets every three months to review study protocols, manuscripts, ethical issues, emergent analyses, and knowledge translation. In addition, the Partnership meets to discuss emerging results and communications with media. Finally, since they were established in 2010, the Cedar Project study has enthusiastically embraced the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, with particular attention to Section 9 (Canada, 2007). The study and has also received ethics approval from the UBC/Providence Health Care Research Ethics Board (REB certificate number: H11-02101).    62 Chapter 4: Narratives of childhood maltreatment and the impacts on family and HIV and HCV vulnerability among young Indigenous people who use drugs in three Canadian cities  4.1 Introduction Although there have been rigorous public health efforts to reduce high risk behaviours that contribute to the HIV and hepatitis (HCV) epidemics among people who use drugs in Canada, the vulnerability of infection among Indigenous people who use drugs continues to be unacceptably and disproportionately high. For example, in 2011, 12.2% (n=390) of all new HIV infections in Canada were among Indigenous people, an incidence rate that was 3.5 times higher than non-Indigenous people. In 2009, a special report from the Public Health Agency of Canada determined that injection drug use remained the primary exposure category for the majority (56%) of HIV positive tests among Indigenous people in Canada, compared to only 14% for non-Indigenous people who tested positive (Public Health Agency of Canada, 2010c). In addition, the incidence of HCV is 4.7 times higher for Indigenous people than non-Indigenous people (Public Health Agency of, 2009; Public Health Agency of Canada, 2010d). These statistics highlight what many Indigenous leaders, scholars, and HIV service providers have known for decades: that HIV and HCV prevention and treatment programming among Indigenous people must extend their focus beyond individual risk behaviours and address the complex social determinants of Indigenous people’s vulnerability to HIV and HCV infection, which are rooted in the legacy of colonization policies and intergenerational trauma (Christian & Spittal, 2008; Duran & Walters, 2004; Vernon, 2001; Walters et al., 2011).    63 Having experienced childhood maltreatment (including abuse and/or neglect) has been identified as a powerful determinant of HIV and HCV vulnerability among people who use drugs (Braitstein et al., 2003; Zierler et al., 1991). For example, Braitstein et al. (2003) carried out a study of adults who use injection drugs in Vancouver, BC and found that participants who had been sexually abused in childhood were more likely to share injection equipment with people who were HIV positive than participants who had not been sexually abused. Further, participants with histories of sexual abuse had a statistically higher prevalence of HIV infection. Previous studies published by the Cedar Project, a cohort involving young Indigenous people who use drugs in Canada, have similarly found that young Indigenous people in Canada who have been sexually abused have increased vulnerability for HIV and HCV infection. For example, Cedar Project research has demonstrated that participants who have been sexually abused and use drugs are more likely to transition to injection drug use, to need help injecting, and to share injection equipment, thereby increasing their vulnerability to HIV and HCV infection (For the Cedar Project Partnership et al., 2008; Mehrabadi, Paterson, et al., 2008; Miller et al., 2011). These results are deeply concerning, particularly in light of multiple inquiries and reports demonstrating that the disproportionately high number of Indigenous children who experience maltreatment and family violence is one of the most disastrous corollaries of Canadian colonization policies and the residential school system (Bopp, Bopp, & Lane, 2003; Canada, 1996; LaRocque, 1994; Public Health Agency of Canada, 2010a) Indigenous Elders and scholars have emphasized that any discussion of childhood maltreatment and consequent HIV and HCV vulnerability among young Indigenous people in Canada must first be understood within the context of historical trauma and how this trauma continues to impact Indigenous families (Barlow, 2003; Chansonneuve, 2005; Hylton, 2002;   64 LaRocque, 1994; Wesley-Esquimaux & Smolewski, 2004; Yellow Horse Brave Heart, 2003). In the 17th century, French and English colonizers made aggressive attempts to Christianize Indigenous peoples in Canada (and elsewhere). This dramatically altered traditional Indigenous family relations by denigrating the spirituality on which Indigenous cultures are predicated and introducing the beliefs that women should be subjugated and children’s autonomy should be restricted (Anderson, 1991; Gunn Allen, 1986). The implementation of the residential school system arguably delivered the most destructive blow to Indigenous families subsequent to European contact. The system was designed and implemented by the Canadian government and various Christian institutions for the purposes of “producing cultural conformity”  (Kelm, 1998, p. 58) by removing Indigenous children from the cultural influences of their families and communities, indoctrinating them into Christianity, so that they could be assimilated into mainstream Canadian society (Fournier & Crey, 1997; Miller, 2009; Milloy, 1999). Between 1874 and 1996, over 150,000 Indigenous children were forced into the residential school system. Four out of five generations of some Indigenous families attended residential schools and an estimated 86,000 living residential school survivors are currently living in Canada (35,000 of whom live in BC) (Aboriginal Healing Foundation, 2007). Extensive government, Church, and Indigenous-led inquiries have revealed that 70-100% of children in residential schools experienced horrifying abuses and neglect at the hands of missionary teachers (Behind Closed Doors: Stories from the Kamloops Indian Residential School, 2001; Canada, 1996; Chansonneuve, 2005; Chrisjohn, Young, & Maraun, 1997). In the aftermath of their experiences in residential schools, many survivors had internalized what they had learned about control and abuse and brought those experiences into their families and communities (Christian & Spittal, 2008; Ross, 2006, 2008). Over generations, families and entire   65 communities became overwhelmed by the number of individuals suffering with unresolved trauma, grief, and anger (Chansonneuve, 2007). The intergenerational transmission of anger, grief, shame, emotional detachment, addiction tendencies, and other harmful stress-coping responses within Indigenous families and across communities has been described as lateral violence (Chansonneuve, 2005; Walters & Simoni, 2002). There is increasing recognition of the far-reaching and intergenerational health, social and economic impacts that colonization and residential schools have had on Indigenous peoples in general (Evans-Campbell, 2008). This recognition includes the awareness that younger generations of Indigenous people are currently struggling with the legacies of intergenerational trauma (Christian & Spittal, 2008; Whitbeck et al., 2009). Furthermore, Indigenous leaders and scholars argue that the collective and intergenerational trauma experienced by Indigenous people in Canada has been perpetuated by child welfare policies that prioritize the removal of Indigenous children from their families, instead of investing in family reunification and traditional healing processes as well as ameliorating socioeconomic and health issues (Christian & Spittal, 2008; Fournier & Crey, 1997). The child welfare system in Canada has undoubtedly contributed to the number of Indigenous families and communities in crisis. In the 2000s, the number of Indigenous children in foster care was roughly triple the number of Indigenous children who were in residential school in the 1940s, when the system was at its peak (Blackstock, 2003). In 2011, Indigenous children comprised just 7% of children under age 14 in Canada, but accounted for 48% of all children in foster care (Statistics Canada, 2013). Qualitative inquiries have been critical to delineating the complicated psychosocial and environmental processes by which people who have experienced childhood maltreatment become vulnerable to HIV risk behaviours in young adulthood. Conventional epidemiological   66 and statistical methods used for these inquiries are limited because they do not address how the temporal, emotional and psychological processes associated with childhood maltreatment influence the perceptions, decisions, and actions that contribute to HIV risk and infection in young adulthood. For example, Clum et al. (2009) conducted a study of the life-histories of 40 young HIV-positive women living in three urban centres in the United States who had experienced childhood maltreatment. The study illustrated that the women used illicit drugs as an emotional avoidance strategy and engaged in high risk sex due in part to difficulties developing trust and intimacy.  Qualitative research has also played an instrumental role in advancing an understanding of the continuing effects of historical trauma on young Indigenous peoples. For example, Goodkind et al. (2012) conducted 74 in-depth interviews with people living on a Diné reserve in the state of New Mexico, U.S.A., 14 of whom were youth. The youth explained that the traumatic history of colonization among their people had resulted in them growing up not knowing their traditions and language, which had in turn contributed to anger, sadness, a mistrust of white people, and difficulty articulating historical pain. In addition, Gone (2013) conducted interviews with 19 individuals at a First Nations addictions treatment centre on a Northern Algonquian reserve in Canada, 11 of whom were either residential school survivors or had parents and/or grandparents who had attended residential school. The clients’ discussions illustrated that their families had shouldered the cumulative “emotional burdens” (p. 84) of residential school experiences and childhood maltreatment for decades and that their alcohol use was a symptom of deeply-felt pain.    67 4.2 Objectives and rationale Indigenous Elders and scholars have emphasized that researchers and professionals who strive to respond effectively to the realities of young, at-risk Indigenous people who use drugs must listen to young people’s voices and acknowledge the impact that intergenerational and lifetime trauma has had on them (Brant Castellano, 2000). However, to our knowledge, no previous research has qualitatively explored the pathways between childhood maltreatment and HIV and HCV vulnerability among young Indigenous people who use drugs or asked about their perspectives of the effects of the residential school and child welfare systems. This represents an important gap in the research, especially given that the intersections of historical trauma, lifetime trauma, and institutional violence have empirically been shown to exacerbate negative health outcomes among young Indigenous people (For the Cedar Project Partnership et al., 2008). The objective of this study was to address this gap in the academic literature by conducting a qualitative study that aimed to generate a deeper understanding of the childhood maltreatment experienced by young Indigenous people who use drugs and how the immediate and long-term emotional responses to that maltreatment shaped the pathways that have led to HIV and HCV vulnerability and infection. In addition, this study sought to highlight participants’ perspectives of intergenerational trauma, child apprehension, and to highlight the importance of having access to healing resources (Brave Heart, 2003; Henderson, 2008; Kirmayer et al., 2003). 4.3 Overview of the study The decision to use a multidisciplinary approach to understanding young Indigenous people’s early childhood experiences, family relationships, and the subsequent trajectories that led to HIV-vulnerability over the life course was based on numerous consultations with members of the Cedar Project Partnership. Since the inception of the Cedar Project cohort in 2003, we   68 have received governance and oversight from the Cedar Project Partnership, which includes Indigenous leaders and Elders, HIV/AIDS service organizations, child and family experts, and community advocates. The Cedar Project’s findings that early childhood trauma (particularly sexual abuse) is a powerful determinant of HIV-risk (Chavoshi et al., 2012; For the Cedar Project Partnership et al., 2008; Mehrabadi, Paterson, et al., 2008; Spittal et al., 2007) was not surprising to the members of the Partnership, as they have long understood the extent to which trauma has impacted the health of families and communities. Meetings with the Partnership affirmed that investigating Cedar Project participants’ lived experiences of trauma using both quantitative measures and qualitative methods would be essential for understanding the pathways that led to HIV-vulnerability and for generating recommendations for wellness and healing. The present study therefore represents a collaborative and multidisciplinary research endeavour between the researcher and the Partnership.  4.4 Theoretical approach informing the study This study was informed by theories that acknowledge the cumulative impacts of colonization − particularly the residential school and child welfare systems − on the lives of Indigenous families today (Chansonneuve, 2005; Duran, Duran, Yellow Horse Brave Heart, & Yellow Horse-Davis, 1998; Fournier & Crey, 1997; Wesley-Esquimaux & Smolewski, 2004). Importantly, this theoretical framework emphasizes that Indigenous families fraught with violence and substance use are also struggling to cope with unresolved historical and intergenerational trauma. It is critical to note that the framework does not blame or shame any individual or community. Rather, it focuses on the systemic oppression and violence that has occurred as a result of state and faith-based policies, and legislation (i.e. the Indian Act), which have in turn undermined traditional Indigenous values, identities, cultures, and self-  69 determination. The study’s theoretical approach was also informed by research that recognizes Indigenous peoples’ inherent strengths, including cultural resilience and a capacity for resistance in the face of multifaceted adversities (Dion-Stout et al., 2001; Kirmayer, Dandeneau, Marshall, Phillips, & Williamson, 2011). Finally, it incorporated knowledge shared at Cedar Project community ceremonies and knowledge translation events in 2012 and 2013, both of which highlighted how powerful the voices of young Indigenous people who use drugs are when they openly share their life experiences and what they need to move forward.  4.5 Review of study setting, participants, and data collection methods This multidisciplinary research used purposive sampling to enroll 30 participants from the Cedar Project who met eligibility criteria, and integrated the CTQ data into the analysis. Cedar Project study staff approached Cedar Project participants who: a) had completed a Childhood Trauma Questionnaire (CTQ) and; b) were open to the idea of having a long conversation with a female researcher about their lives. Nearly all participants were interviewed in the Cedar Project study locations between October 2011 and June 2013. A majority of the interviews were carried out in private offices at Cedar Project study sites; two took place in private meeting rooms at local service organizations. Of the 30 participants who participated in this study, 18 (60%) were women and 12 (40%) were men. Seventeen participants (56.6%) were based in Vancouver, 11 (36.6%) were based in Prince George, and two (6.6%) were based in Chase. The participants’ median age was 32 at the time of their in-depth interview, (Range: 21-39). In total, five participants (16.6%) were HIV positive, 12 (40%) participants were HCV positive. Eighteen participants (60%) had ever used injection drugs. The in-depth interviews relied on a loosely structured topic guide that allowed participants to contextualize any experiences of childhood maltreatment, substance use, and HIV   70 and HCV risk within temporal or causal sequences of events, individuals, and environments. The topic guide covered circumstances of childhood and adulthood, emphasizing participants’ recollections of childhood experiences and emotional responses, family relationships, transitions into risk behaviours such as drug use and sex work involvement, intimate relationships, mental health issues, and sources of strength. The interviews were audio recorded using a digital recording device. With the aim of listening to narratives of experiences, participants were encouraged to ‘start at the beginning’ of their life story, but we did not enforce a set timeline because we wanted participants to articulate their complex and interwoven memories in a narrative that felt natural. In this analysis, we also integrated participants’ information that  provided in the CTQ. The CTQ is a widely used retrospective and self-reported 28-item inventory that measures five types of childhood maltreatment: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect (Bernstein & Fink, 1998). As suggested by Bernstein & Fink, the CTQ subscales were coded according to four pre-set thresholds to categorize the severity of childhood maltreatment experiences: none, low, moderate, and severe. Further details on the study setting, participants, data collection, and on how the CTQ measures of maltreatment were coded may be found in Chapter 3 of this dissertation (pages 58-60). 4.6 Analytical approach An interpretive thematic approach was used to analyze the qualitative data (Starks, 2007). This method of analysis allowed for engagement as witnesses of the accounts of childhood maltreatment and associated processes that prompted stress-coping responses among Cedar Project participants (Starks & Trinidad, 2007). Stress-coping in this study refers to both the risk and protective strategies that Cedar Project participants used in order to adapt to – and survive – emotional, physical, mental, and spiritual stresses related to historical and lifetime traumas. Each   71 participant was given a pseudonym in the analysis to protect their confidentiality. Codes were created by categorizing specific statements into groups of meaning that represented subjects of interest, exploring taken for granted assumptions and paying special attention to the descriptions of what participants experienced and how they experienced it (Starks & Trinidad, 2007). For example, in this study, special attention was paid to participants’ descriptions of childhood sexual abuse, physical abuse, emotional abuse, and neglect, in addition to the sources, causes, and consequences of maltreatment. The strategy of “constant comparison” (LeCompte & Schensul, 1999, p. 75) was used in the reintegration of the data, wherein central themes and relationships were drawn across all of the participants’ narratives (Starks & Trinidad, 2007). The data were organized and coded using NVivo 10, a qualitative software package (QSR International Pty Ltd., 2012). Words, phrases, and quotes that illustrated the concepts, patterns, and themes were drawn from the transcripts. The analysis was continually evaluated during frequent discussions with study staff thesis committee members, and the researcher’s mentors from the Cedar Project Partnership, which strengthened the credibility of the data. In addition, cross comparisons with existing Cedar Project studies and the triangulation of quantitative and qualitative data enriched the rigor and trustworthiness of the analysis. The coding scheme and analysis were presented to the Cedar Project Partnership on December 6, 2012, and members provided critical feedback and consensus about the themes to be interpreted and the associated recommendations. Extensive notes were taken to document all decisions and insights at each stage of the research. Finally, descriptive techniques that were used to analyze the CTQ data included frequencies, means, medians, and cross-tabulations. Further details on the analysis again may be found in Chapter 3 (pages 61-63).   72 4.7 Quantitative study findings A summary of the CTQ results are demonstrated in Table 4.1. The majority of participants’ maltreatment experiences had been ‘severe/extreme’, with the second highest proportion being ‘none/minimal’, followed by ‘low/moderate’ and ‘moderate/severe’. This was the case for each abuse and neglect sub-type with the exception of emotional neglect, which had a more normal distribution. Most participants had experienced more than one sub-type of severe maltreatment. Five participants reported severe experiences for each maltreatment type. Sixty-nine percent of participants who had experienced severe/extreme sexual abuse had also experienced severe physical abuse, and 77% of participants who had experienced severe physical neglect had also experienced severe physical abuse (data not shown). Most participants had experienced more than one type of maltreatment at the same time, while others experienced different types of maltreatment separately or intermittently. Only two participants reported that they had had no experiences of abuse or neglect on the CTQ and one participant reported low/moderate experiences for each maltreatment type.   Table 4.1: Frequencies and severity levels of maltreatment experiences measured by the Childhood Trauma Questionnaire among Cedar Project participants (n=30)* Abuse type None Low to Moderate Moderate to Severe Severe to Extreme Sexual Abuse 9 (30%) 4 (13.3%) 2 (6.7%) 13 (43.3%) Physical Abuse 10 (13.3%) 2 (6.7%) 2 (6.7%) 15 (50%) Emotional Abuse 6 (20%) 6 (20%) 2 (6.7%) 14 (46.7%) Emotional Neglect 8 (26.7%) 9 (30%) 3 (10%) 7 (23.3%) Physical Neglect 8 (26.7%) 3 (10%) 4 (13.3%) 13 (43.3%) *Frequencies may not add up to 100% due to missing answers   73 4.8 Qualitative study findings Excerpts from the interviews are discussed in order to illustrate the five broad themes that emerged from the qualitative analysis and the patterns and concepts that characterize them: complexity and interconnection; stress-coping mechanisms in childhood; emotional and psychological escape; family dislocation and separation; stress-coping mechanisms; and healing in later life. 4.8.1 Complexity and interconnection Participants’ narratives revealed the complexity and interconnectivity of their maltreatment experiences and their emotional and psychological responses to those experiences. This becomes particularly evident when the narratives are analyzed in relation to the five types of maltreatment that are discussed in the study. Participants usually provided their accounts of early childhood trauma without prompting, perhaps because they had been clearly informed about the study objectives.  Sexual abuse Twenty-one of the narratives included stories about being sexually abused, which was higher than number who reported sexual abuse in the CTQ (n=19). Participants’ accounts of sexual abuse were either vivid or vague, which may have reflected how comfortable they were sharing about their memories as well as the clarity of their memories. Most participants recalled that their first experiences of sexual abuse occurred before they were 12 years old. Two participants were adolescents when they had their first experience of sexual abuse. Participants’ stories of sexual abuse ranged widely in severity (from attempted sexual contact to rape) and duration (from isolated to chronic). Four participants recalled having one or two isolated and unexpected sexual abuse experiences. This was the case for Max, who was adopted into a white   74 family when he was a baby and placed in foster care as an adolescent. Max explained that he had to abruptly leave one of his foster homes because: “(it) was just before my 14th birthday and I got raped by one of my foster dads.”  Nine participants described chronic sexual abuse experiences that began in early childhood, lasted for multiple years, and often had more than one offender. This was the case for Leanne, whose father had been physically abusive toward her in early childhood but changed after he started to use crack. When she was eight years old her father coerced Leanne into smoking crack before he began to sexually molest her:  Uh, and then in later years actually (my dad) used to sexually abuse me. I don't know what the hell changed in his head. He started getting on crack and that's when his whole mind just, like, he wasn't him anymore. At least when he was drinking and smoking weed, yeah, he'd get anger from his own issues but he was still caring and still, like, oh, you know, “You need to go to bed” and “this is this” and “here's at least dinner.” …He just started smoking crack all the time. I was like, everything became about crack. …He told me to come here and put a crack pipe, put crack rock on the pipe and stuck it to my mouth and said inhale….and I got addicted right after that so it didn't matter what he wanted to do as long as I got the crack I didn't care. So at nine years old my mentality is already just hooked on the drug and that's why sexual abuse became even easier for him. 'Cause I didn't care. If there was drugs. …I couldn't lie anywhere without getting into actions with him and I was just like, “What the hell is this bullshit?” …And then I kind of got used to it as a kid.   Leanne frequently ran away and when she was nine and a half years old she was taken into foster care by the Ministry of Children and Family Development. When she was approximately 12 years old and in her second foster home, the man who had been her foster father also began to sexually abuse her which eventually led her to living on the street:  He'd start taking pictures inappropriately. Uh, he started, uh, I got really sick with mono and wasn't allowed at school so I'm lying on the couch and I feel like I'm dying, well, he'd start touching inappropriately and I'm like, “What the hell are you doing?” He tried taking, he took my shirt off so I'm lying there naked and I'm like this is unbelievable. I grabbed a blanket and wrapped it   75 around me. I was like, this is not happening again. So eventually I wound up running away.  The distressing emotional and psychological consequences of sexual abuse were evident in each of the participants’ narratives and these consequences were damaging for participants who either had isolated or chronic experiences of sexual abuse. Participants used words such as “disgusted”, “ashamed”, “helpless”, “terrified”, and “hurt and betrayed” to describe how they had felt after being sexually abused. Kyle shared his experience of sexual abuse within the first few minutes of his interview in response to being asked how he felt growing up with a father who was a residential school survivor and living in a tiny trailer on a remote reserve. Kyle’s narrative clearly indicated that it was difficult for him to talk about his experience of sexual abuse and that he continued to be deeply psychologically impacted by it:  I guess, yeah, I was sexually, uh, assaulted when I was a kid so that really played in with my emotions too, I guess. Um, my dad, when he used to get drunk, he used to more or less force me to go, this was his way of playing with my, my private parts and stuff was to force me to go and have a bath and that. Even, like, middle of the night when the lights were out and stuff. It's just not something I want to get into.  Participants’ stories of sexual abuse revealed that most of their offenders were members of their families or communities. Sexual offenders were usually male relatives, males close to the family (such as a babysitter), or males in a guardianship role, such as a step or foster father. In three cases the sexual offenders were female (two were female relatives and one was a female known to the family). Every participant who was sexually abused described complex emotional responses. On the one hand, they felt profoundly betrayed and hurt by the offender. On the other hand, they were confused about why the abuse had happened to them and deeply angry at the offender. These feelings were consistent regardless of the severity of the sexual abuse. Connor   76 described his second experience of being sexually abused when he was 12 years old by an adult man in the community who had taken time to build a friendship with him. His account of betrayal mirrored the accounts of many other participants:  I was hanging out with this older fella and stuff like that and my friends, right? And, uh, we went to his house and we were watching TV and they were like, ‘Hey, you guys can sleep over if you want’ and stuff like that and, yeah, and so we got in his house and whatever for, like, quite awhile and all of a sudden he started saying, ‘Touch this, touch that’ and I'm like, ‘Should I? I don't think I should.’ And, like, he was getting really sexual on us, right? So we were like, ‘No, we're going to leave’ and stuff and, and that was another traumatic experience. I was like 12 or something like that. …I felt really hurt and betrayed because I knew the, the person. And then when you trust somebody and you know they're not going to hurt you, why would they do that kind of stuff? All you got is questions and answers, right? I always have questions and answers. It was really, it was hurtful. Why would you say that you're my friend and you let me in your house and we do all these cool things and you're a very nice person and you want to move into that kind of stuff? I'm not, you know? I'm not that way. I'm not, I'm not old enough, you know? Beginning, you know? And what to know, what to do with that kind of stuff? So I just really, I felt really anguished about that person, right?  It is important to note that three of the young women in this study reported that they had not experienced any childhood sexual abuse, but had entered into their first romantic and sexual relationships at 11-12 years old with male partners who were 10-30 years older than them. In each case, the women recalled being overpowered and intimidated by the older man, feeling betrayed, and angry and disgusted by him, and eventually coerced into sex work by him.  Physical abuse  Eighteen participants described childhood experiences of physical abuse in their in-depth interview, which was just under the number (n=19) who reported physical abuse in the CTQ. The most common experiences were being slapped, punched, choked, or whipped with sticks, ropes, or belts. Physical abuse experiences varied in intensity and frequency as some participants   77 received consistent corporal punishments such as spankings or slaps, some endured occasional but extreme injurious beatings, and others, like Karen, were severely physically abused on a regular basis. In describing her experience of physical abuse, Karen recalled that “[for] every little thing I did wrong I’d always get a punch in the face.”  Physical abuse ensued before age six for most of the participants and lasted until late adolescence. In most cases, parents were the abuser. The majority of participants who had been physically abused gave accounts of violence that were intermittent and shocking and remembered feeling fearful and anxious in their home (i.e. “walking on egg shells” and feeling anxious and “stressed out as a kid.”). Jane’s narrative indicated that not knowing what would trigger her mother’s anger and abusive behaviour had been the most traumatizing element of her physical abuse. Her description of the home environment she grew up in was similar to descriptions given by other participants who had been physically abused:  “We didn't know like, we'd get up, we didn't know what kind of day it was going to be, right? That was hard. …Like if I knew I was going to get a beating I could prepare myself. Right? But I could never be prepared because it always happened at the spur of the moment. Like, (mom) just like, fuckin' like, snapped. Unpredictable. Yeah. And we didn't know whether, you know, there was going to be because of a fuckin' spot on the glass fuckin' spot on the floor or someone didn't clean up or just stupid things that weren't important, you know?”   It is important to note that five of the participants (two men and three women) who had experienced physical abuse made disclaiming statements that diminished the severity of their experiences, such as “it wasn’t too bad”. At first, those participants justified their parent’s harsh corporal punishments because they had “deserved it”. However, after recalling those experiences the participants began to acknowledge that it had hurt them. This was the case for Howard, who   78 at first blamed himself for and minimized the intense corporal punishments he regularly received from his father, but later admitted that he had felt deeply frightened and hurt. Howard explained: I look, as I look back I think of myself as the, the mental person. I was the person. I was the person that was causing, I gave the most trouble. I mean, my dad was a little more stricter than he could have been, I think, at some times. There was no real beatings or anything. We, we did get our asses slapped if we, uh, did some bad shit. I mean he had one thing with a stick. He, he’d give us lashes on our hands but that was like, I mean, if you did something bad you’d put your hand out and he’d give you a little whip on the hand or whatever. The worst part is that he made us pick out the stick. He’d take us, he’d take us on walks and, yeah, he’d pick out the stick while we walked. How’s this one? (makes a whipping sound) He makes that whipping noise-, you know that noise it makes in the air? Yeah, so. That was, yeah. Those weren’t fun. It didn’t leave marks or anything like but man did it hurt. Don’t pull your hand up either. When he came down. Twice more (imitates noise).  Emotional abuse  Although twenty-two of the thirty participants reported that they had experienced emotional abuse in the CTQ, only nine spoke about it during their life history interview. Parents and guardians were the most common perpetrators of emotional abuse. The experiences of emotional abuse that were described included being insulted with cruel names, being subjected to excessive controlling behaviour, and being physically and verbally intimidated and threatened. In most cases, participants’ accounts of emotional abuse emerged as they recalled physical or sexual abuse. For instance, Ellen was abused unrelentingly by her mother, who was a residential school survivor and struggled with severe substance use. One account of her mother’s physical attacks indicated that her experience of physical abuse had had an emotional component:  One time when I went home and I was holding my baby sister in my arms (mom) grabbed a knife and she held it to my face and she’s like, ‘I should just fucking cut you up and chop you up right now and feed you to the dogs. Nobody would even know that you were, went missing. I’ll just tell them that you ran away. Nobody will ever know that you came home.’ ‘Cause I went home on my own, so. I started crying and I kept asking her, ‘Please, don’t do   79 that.’ And she’s holding this big knife in my face and it was all fucked up like that.  Physical and Emotional Neglect Participants’ narratives of neglect demonstrated that it was intertwined with other types of abuse and neglect. Sixty percent of participants recalled being neglected by their parents or caregivers, whereas 70% and 71% of participants reported some degree of emotional or physical neglect in the CTQ. All the participants who shared experiences of neglect remembered being aware as children that their parents or caregivers were struggling with addiction. Eight participants said there were times when they did not have enough to eat due to poverty or because their parents spent grocery money on alcohol or drugs. Nine participants recalled that their parents hosted raucous parties at home and that alcohol and drug use intensified as the parties progressed. As a result, their parents became less attentive to their safety and they were in greater danger of being hurt. For example, Bella’s mother had left her in the care of her grandparents, who then raised her. Though Bella explained that her grandparents were not abusive toward her, when they drank they had been unable to protect her from being sexually abused by her uncle. Bella’s account of being neglected by her grandparents during parties revealed the interconnection between neglect and sexual abuse:  Um, my grandpa kept asking (my uncle), asking me to go get him when they would drink. And I’d be asking him why and I’d say, ‘No, I don’t want him here.’ But I didn’t want to tell my grandpa what was going on when he’d pass out. ‘Cause (my uncle would) go in the other room and touch me and stuff. And yeah. But he’d always party with him and every time they partied, that was when it would happen, so.  A number of participants’ experiences of neglect involved being left alone for periods of time from a very young age onwards. For example, Graham described waking up in the middle   80 of the night and realizing that he had been left alone in the house. His feelings of fear highlighted the emotional impact of physical neglect:  It's like I said, I grew up in an alcoholic home, I wake up in the middle of the night, nobody home. Scared as a little kid. I'd be walking in the middle of the night, down the middle of the street, crying. Not a soul could hear me. Not anybody, nobody acknowledged me. And, um, just once or twice out of those times as a kid I actually found my parents at a party. Asking me what I was doing there and this and that, and I said nobody is home.  Many participants who had been neglected shared Graham’s sense of being vulnerable to harm when their caregivers were absent –particularly when they were put in the care of unfit or inappropriate individuals. For example, Emma described the significant neglect she had experienced when she was six years old and her mother left her and her two younger cousins alone in their apartment for approximately three weeks. Her mother had instructed her to ask their downstairs neighbour for help when the children needed money for food. Emma’s story provides another illustration of the link between neglect and sexual abuse while describing the profound reasoning of a six-year old who was able weigh her own security against her responsibility to care for two younger children:  (Mom) said if I ever needed something, if I was ever hungry, to go down there and he (the downstairs neighbour) would help me out. And, he gave me 50 dollars. I was 6 and half or something. And I was going to leave right away, but he wouldn’t let me leave. He basically, just told me to sit there with my legs open and he’d do whatever. Play with himself. And then it wasn’t sexual abuse or anything, that you know, he wasn’t touching me, he was just lookin’ at me. But I thought, well there’s 3 of us kids that I have to feed upstairs, right? And, so I did it. I did it once a week for 3 weeks. And I didn’t hear from my mom or anything. Um, I don’t have a clue where she was.  Ellen was among six of the young women in this study who disclosed that they had often been left alone in addition to having the overwhelming responsibility to care for younger   81 siblings. Ellen had not only been responsible to care for younger siblings starting at the age of six, but had also been physically abused. As a result, she felt that she had missed the opportunity to be a child:  (Mom) always beat me up. That's why I always ran away. I wasn't allowed to play with my friends. I was, every time I, she told us she was pregnant I'd start crying…'cause she was always at bingo. I was the one that raised them. There was a point where my second youngest sister, Sally, was starting calling me mom.  Lastly, neglect left participants feeling rejected physically and emotionally by their parents. For example, Graham explained that he learned to expect rejection from his mother who had rejected him from the start. He explained:  (She) told me that I was a mistake so I just kind of, I just, you know? I'm used to not getting anything from her. Nothing at all.  Witnessing violence Fourteen participants vividly described instances of being witness to violence between their parents, between their parents and siblings, or between other family members. Although the CTQ did not measure such instances, it is salient to note them because they constitute an additional dimension of trauma within the family and community that is closely linked with other forms of childhood maltreatment (Hamby, Finkelhor, Turner, & Ormrod, 2010). The participants remembered witnessing beatings, sexual assaults, attacks with weapons, and verbal threats and abuse. Three of the young women in the study recalled witnessing their sisters being sexually abused by male relatives. For example, Chloe recalled her grandfather sexually abusing her sister (Nina):  One of my very first memories of my grandfather...he was sexually abusive to my mother and to, uh, Nina, and that was one of my first memories was, um,   82 seeing him doing something to, um, Nina. I could just see in the corner. Yeah, that was like one of my very, very first memories. Um, I didn’t understand what he was doing. I didn’t put it together until I got older.  In general, participants associated feelings of intense fear and helplessness associated with these incidents. However, their narratives also emphasized that violence was normalized in their home. For example, both of Katrina’s parents were regularly violent toward each other and their extended family members:  My mom and my dad always used to fight in front of us. That would be their party. Yeah. Someone was always getting hurt though. Yeah. Or, uh, my dad's brothers, they would fight each other. …(when) they were drinking you knew it was going to happen. They were going to fight. Yeah, we'd go lock ourselves in the bedroom. Watch TV in there and play games while they partied in the living room or whatever.  Participants recalled becoming angry about the violence in their lives as they grew older and trying to intervene in it or prevent it, which required them to put themselves at risk. Katrina went on to share the story of how she had tried to protect her mother:  We used to have to sit on my mom just for (dad) to stop hitting her and then, uh, yeah, he stabbed her when we were sitting on her cause he couldn't get to her anyway. So he just stabbed her in the arm.  In sum, participants’ detailed narratives of their childhood maltreatment experiences reflected the complexity and interconnectivity of these experiences and their psychological and emotional impact. For the majority, emotions of shame, confusion, and loneliness later developed into deep-seated resentment and anger. For example, as a child, Helen had been severely physically abused by her father, who was a residential school survivor, and sexually, physically, and emotional abused as well as physically neglected by multiple offenders. She   83 explained how the psychological, emotional, and spiritual impacts of those experiences had brought her anger and deep despair:  I was really, really angry. I was very angry. I remember when I was 18, I was very angry and I hated the world and I hated life and I hated the Creator and everybody. I, I was so hurt and I was so hateful. You know, how dare you put me through this. I never done anything to you or anybody on this earth and yet I have to suffer so much. You know?  4.8.2 Stress-coping strategies in childhood The second theme that emerged from participant’s narratives was their development of stress-coping responses to trauma in childhood. Three such responses were identified: 1) searching for safety; 2) telling someone about the abuse; and 3) seeking emotional and psychological escape (avoidance). All of the narratives portrayed children who exhibited incredible resourcefulness and courage in the face of danger and adversity.  Searching for safety Nearly all of the participants’ narratives included descriptions of the safe places and safe people they sought out for self-preservation when they were in danger. The places they sought for immediate and temporary safety included secret spots or “forts” in the forest, rooms with a lock, closets, and the spaces underneath staircases and beds. Sarah explained the strategy she used to find safety from the chronic sexual abuse by her step-father:  I was, like, molested from my mom's boyfriend and husband. So, from when I was, like 5 until I was 11. Every day or every second day (whispered). …I was getting molested at night, like, ugh (makes a grossed out sound and starts laughing). (Mom) would go out to the bar and leave me and (my sister) home with her dad. Like, I’d liter-, we had bunk beds, right? The bot-, I’d sleep on the top...I’d be right – I was skinny as a mini. In between the wall and this would be the mattress. I’d be, like, laying there and he’d still get me out. Just, I’d like, try and like, you know, be safe. Uh, my mom’s friend, they were staying there for a week or two. They saw him bring me out of the room and she tried to tell my mom. My moms like, “Oh, you’re hallucinating,” or   84 something. My aunt, I call her my auntie but she’s a family friend. So, she tried to help. Mom was just with the guy for money and he was paying the rent and everything, so.  The safe people that participants identified may not have known what they were going through at home, but still offered them comfort and refuge. Participants frequently mentioned that the company of siblings and cousins whose safety was also at risk gave them a feeling of protection, as the children relied on each other for comfort. In addition, participants described running away to the nearest homes of aunts, grandmothers, or friends who offered comfort when they were frightened. However, it is important to note that some participants’ experiences of betrayal in childhood were so severe that they felt they had no safe place to hide and no safe people to turn to for protection. These participants sought safety on the streets and came to rely on themselves alone for security. When running was not an option, participants avoided adults or kept emotional distance from them in order to create safety or strengthen their sense of emotional security. Todd learned at an early age that he could not trust or receive comfort from the adults in his life and that keeping distance from them was his safest approach:  I’m not going to hug people that hit me. I don’t really, you know, I just stayed away from them as much as I possibly could.   For Graham, evading adults during parties at his house kept him safe most of the time, although he recalled a frightening close call that occurred when he was 8 years old:  It was hard sometimes. I mean, I kept my distance from all the grownups except for one night which I didn't expect. I woke up with one of my uncles behind me. Like...it was just, I just got up, grabbed my blanket and I went in my room and I locked it.    85 Telling someone Most participants described a critical juncture in their childhood at which attempts to find safety from abuse or neglect failed, leading them to make the difficult decision to disclose their maltreatment to a non-offending adult, typically a parent or family member, teacher, or social worker. The majority reported that the adults’ initial reactions were either supportive or unsupportive. Eight described at least one supportive response to their disclosure of sexual and/or physical abuse from adults who appeared to believe them. As a result, the offender was charged by the police and/or prevented from having further contact with them. These eight participants remembered receiving comforting, sympathetic, and reassuring responses as well as affirmations of their sense that “what was going on at home wasn’t normal” or “ wasn’t right”. For example, Helen described how her mother responded when she disclosed her experience of being raped by a male babysitter when she was approximately five years old:  She knew something was wrong and, um, so I finally told her. So, I told her what had happened because I was bleeding down there and, uh, and she started crying and everything and she’s hugging me and from that point on she’d never hire him again.  For participants who had received supportive responses, sharing their stories and asking for help as a positive experience that reinforced their trust in adults. In contrast, four participants who received ambivalent responses (neither completely positive nor completely negative) decided not to tell anyone else about their experiences of maltreatment and did not disclose those experiences again until they were adults. Twelve participants received an unsupportive response from the adults to whom they had disclosed abuse (sexual in all cases) and felt betrayed by those adults. The unsupportive responses included being disbelieved, ignored, physically punished, verbally shamed, blamed for enticing the offender, or forced to leave home. For example, Ellen’s   86 first sexual experience occurred when she raped by a 21-year old man at the age of 12. Ellen remembered that when she told her mother what had happened, her mother said “you don’t even have hair and you’re already fucking around”, which both shamed and blamed her. Participants who received such unsupportive responses said that the responses caused significant confusion and anger and led them to deeply mistrust adults’ ability to care for them and provide safety. Some of the participants recalled that their entire community responded unsupportively to their disclosure of abuse by gossiping about them and criticizing them.  Seeking emotional and psychological escape  The majority of participants explained that they developed the childhood stress-coping mechanism of emotional and psychological escape, or, avoidance. This was revealed in participants’ accounts of how they detached from traumatic experiences and began practicing self-harming behaviours or and using alcohol and drugs. Participants detached emotionally and psychologically when they experienced traumatic events in order to attain a sense of emotional and mental security. For example, they coped by “showing absolutely no emotions”, going “blank and [becoming] blocked out”, and “putting up a good front” to mask their pain from those who hurt them. Many participants who attempted to detach said that they made a conscious effort not to cry while they were being hurt. Karen remembered that she dissociated in order to psychologically cope with the frequent and severe emotional and physical abuse she received from her mother, who had spent many years in residential school:  I remember (mom) was teaching me, uh, Our Father, who art in Heaven. You know, that, that, um, prayer? And, uh, she’d say words and I’d try to remember it and, uh, like, I don’t know, she used to try and, uh, make me say it perfect and things like that, and, uh, yeah. And I’d say one word wrong and she’d   87 fricking hit or punch. Punch me in the face and after awhile I wouldn’t even cry anymore. Just, it wouldn’t hurt no more.  Eight participants engaged in self-harming behaviours in order to cope with stress. They began doing so between the ages of 11 and 13 years old to “numb” their emotions, particularly their anger about being maltreated. Their most common self-harm behaviours were cutting, choking, and punching or hitting themselves and they associated the behaviours with suicide ideation and feelings of hopelessness. Leanne recalled that being sexually abused by her father and feeling frustrated about her lack of safety in foster homes led her to begin harming herself because it helped her to feel calm and in control of her body: It was just like I could be in the most extreme agony, wanting to cry. Wanting to punch something and if I cut I'd see that blood come out and it was just like…it's ok. I'm bleeding. Wipe it away and, like, you know, nobody else could hurt me but me.  Lastly, all of the participants began using substances (marijuana and alcohol) to manage their feelings. Participants initiated substance use between the ages of six and 17 years. Most initially saw substance use as a way to connect with their family and friends. These early experiences were mostly fun, although the participants acknowledged that they also used substances to “escape” from the pain of loneliness, fear, and sadness. This motivation was described by Cam, who was physically abused by his father, a residential school survivor and a single parent who struggled with anger and alcoholism: I started drinking to see what it felt like. See what the big deal was. Why my dad did it all the time. And then I found out and, I don't know, I guess it seemed fun. ‘Cause it made me happy and feel weird, drunk. …Made me open up more. So, freely right? Talk a lot more than I would.    88 Most of participants began using hard drugs in their mid-adolescence and their substance use rapidly escalated to hard drug use. Transitioning from marijuana and alcohol to smoking crack cocaine was a common story in the narratives. Participants recalled discovering that crack was a particularly effective drug for psychological escape because it gave them the immediate sensation of being “numb” and “covered up” unwanted emotions and thoughts related to their maltreatment experiences. 4.8.3 Family separation and dislocation  The third broad theme that emerged in the participants’ narratives was family separation and dislocation. Participants described this response to childhood trauma as a dynamic process that happened in stages over time. The two most commonly discussed circumstances of being separated from family were 1) alcohol and drug use in the family, and; 2) being taken into the child welfare system.  Alcohol and drug use in the family All of the participants’ life histories included heavy alcohol and drug use in the family. Their narratives demonstrated that alcohol and drugs played a major role in the breakdown of family functioning and the escalation of family violence. Fourteen participants described their parents and caregivers “alcoholic” because they drank heavily “all the time” and then became “abusive”, “mean” or physically and emotionally distant. Others described one or more of their parents and caregivers as a “drug addict” or “junkie” because they used crack, heroin, and other hard drugs. Some participants began using substances at very young ages in order to spend more time with family members, reduce the emotional distance between themselves and family member, and feel that they belonged to their family or community. This was the case for Kyle,   89 who had hid in the woods as a child to escape from the intense parties in his father’s home, then later began drinking:  So, I sort of started drinking, started falling into my party life, too, when I was about eleven, twelve years old because that was the thing. That was, that’s what was going on in the town. That’s what everybody was doing, so. And I started drinking.  Many participants recalled that alcohol and drug use caused the family situation to go “from bad to worse” and “just took over” the family. They described feeling disappointed, frustrated and despairing as they realized that their parents were unable to care for them or their siblings. For example, Chloe recalled that in the weeks prior to being taken into foster care her family had had no food and her mother’s drinking had gotten worse:  Yeah, and, um, anyways we would go to our friend’s and her mother called social services cause I went there, like, really hungry and she had had it cause she had seen us and she lived like a block and a half away and her mo-, her mother had seen us going, she knew what was going on. Um, yeah and just before that I remember, yeah, there was a lot of drinking in the house. Having to take, me and Trina were the oldest, having to take my mom upstairs and dress her and put her in bed or take her out of the washroom when she was, like, passed out. Taking care of her, basically. I remember once when, it still makes me smile and hurt too, when we were kids we took her to the top of the stairs and we dropped her on purpose. I don’t think we thought it was on purpose at the time but we were pretty careless with her. Um, yeah, then my, Eleanor took on the role of being the caregiver. I took on the role of showing absolutely no emotions.   Being taken into the child welfare system  Being relocated to foster homes or group homes dislocated participants from their parents, siblings, and extended family members. Twenty-five of the participants had been placed in the child welfare system at least once. In some cases, a family member, friend, teacher, or heath professional had filed a report to the Ministry of Child and Family Development (MCFD),   90 which subsequently took custody of the children. However, it is important to note that four participants’ parents voluntarily put them in foster care and two participants called MCFD themselves and requested to be placed in foster care.  The amount of time that the young people in this study spent in foster care varied greatly. The shortest stay in foster care was two days and the longest was fifteen years. Most of the participants had been in and out of foster homes and/or group homes multiple times in their childhood. In addition, five participants had been adopted in infancy or early childhood because their single biological mothers struggled with poverty, alcohol, and drug use. Two of these had been placed in foster care by their adoptive families when they were adolescents. Participants’ vivid memories of being taken away from their families by MCFD indicated that the experience exacerbated the emotional and psychological impacts of existing trauma. Participants were “very afraid”, “confused”, and “frustrated” when they were contacted by social workers and transported to foster homes. They recalled feeling “awkward” and “homesick” when they were placed in a foster home with new adults who were strangers and expected them to abide by new sets of rules, values, and routines. Some participants who had been placed into foster care with their siblings were subsequently separated from those siblings because their foster parents could not manage so many children. This amplified the participants’ fears and anxieties.  Loneliness, intolerable living conditions, and feeling unsafe drove many participants to run away from foster homes and live on the streets. Leanne explained that living on the streets allowed her to choose where she slept, even though she was sleeping rough. Ultimately the streets provided her with a greater sense of safety and security than multiple foster homes had:    91 I learnt that safety is wherever I lay my head on my down. Not where they put me. So I always made my own, my own way…I just rather stay homeless or slept on the street than sleep in a (foster) home.  Participants who had been in and out of the child welfare system throughout their childhood repeatedly expressed the view that the system had prevented them from maintaining relationships with their families. They often had large memory gaps regarding the whereabouts and wellbeing of the family members they had been separated from. In some cases emotional and physical dislocation from family had defined participants’ entire childhood. For example, when Connor was 3 years old he and his siblings were abruptly removed from their parent’s care. Both of Connor’s parents had attended residential school, struggled with heavy alcohol use, and were violent. While Connor understood that his family was in crisis, he was deeply angry with MCFD because it had permanently separated him from his family. He explained:  Yeah, cause they were drinking. My dad was always drinking and fighting my mom, I think is the main reasons why (we were taken). That's all I know. Yeah, that's all I remember. I don't remember them. I don't remember being taken away so...I just remember living in foster homes all my life.  4.8.4 Stress-coping mechanisms later in life, and shifting perspectives on family  The fourth theme that emerged from the participants’ narratives was stress-coping mechanisms developed in later life. Most of the participants indicated that childhood maltreatment and separation from their families and communities created years of cumulative trauma. The impacts of this trauma included ongoing family separation, interpersonal violence, homelessness, incarceration, involvement in sex work, and vulnerability to HIV and HCV infection. Participants concurrently sought out new stress-coping mechanisms. Two such mechanisms were predominant in the interview data: 1) on-going self-medication; and 2) gaining   92 a better understanding of the role of intergenerational trauma in the family. The first mechanism is particularly salient to this study because it is directly associated with HIV and HCV risks. Self-medication When participants reflected on their lives as late adolescents and young adults, frequent memories and emotions related to their childhood came to the surface. These emotions tended to cause intense distress, which was difficult for participants to cope with. Some participants explained that they preferred to avoid unwanted memories or feelings related to their childhood, but understood that their past had been affecting them negatively nonetheless. Most of the participants said they used alcohol and drugs to cope with stressors or “triggers” that caused them to relive their psychic injuries from their childhood.  Many participants explained that using alcohol and drugs allowed them to “forget”, “stop thinking”, “cover up pain”, and “numb” themselves. They also used alcohol and drugs specifically to cope with the pain of negative self-beliefs developed in childhood (i.e. they were “disgusting”, “never good enough”, “undeserving”, “bad”, “useless”, and “a failure”). For example, Jane’s drug use reflected the negative beliefs that she had developed in response to the severe maltreatment she experienced as a child (physical and emotional abuse, neglect, and witnessing violence):  I use drugs so I don’t have to feel, pretty much like everybody. And I keep coming back to the drugs [whispering] because I don’t feel I deserve a better life. It took me many years to say that [crying]. But I know. It’s why I clean up for so long and then I end up back here. ‘Cause everything goes good and then sometimes too good and I sabotage myself. And I honestly think that comes from my childhood. Never being good enough. [crying].  Eighteen participants told stories about transitioning from smoking drugs to injecting drugs and eventually re-using injection equipment. They began injecting drugs in late   93 adolescence or young adulthood after discovering that it was a powerful way to disconnect from memories and associated emotions and to cope with pain. This was the case for Sasha, who had been victim to severe sexual, physical, and emotional abuse in childhood; had witnessed extreme violence between her parents, who were both residential school survivors, and; had been sexually assaulted by a family member when she was 16 years old. Sasha described the moment when she made the decision to try injection drug use at 22 years old:  And I was asking questions like how does it make you feel, like, tell me? She just told me it makes you feel awesome so I was like, hmm. And I know, I knew, like, her story, what she was going through, like, a lot. So if it made her feel awesome it’d probably make me feel awesome (laughs). …You been through more shitty stuff than I been, I want to feel like you do, kinda thing, so. And she said, she said, I’m not gonna do it for you. You gotta buy your own stuff so I went and found my own stuff and she said she wanted me to buy her dope cause just in case of something happened.  Participants recognized that using alcohol and drugs to suppress memories, emotions, and negative self-beliefs increased their vulnerability to HIV and HCV infection. Five participants were HIV positive and twelve were HCV-positive. Each expressed despair as they remembered giving self-medication a priority over taking precautions to avoid contracting HIV and HCV. This was the case for Connor, who started using injection drugs after and became HIV-positive after he and his brother aged out of the foster care system. He and his brother did not subsequently have a relationship with their parents and other biological family members. This caused both of them profound loneliness, confusion, and anger, and both turned to drugs: (My brother) didn’t tell me he had HIV then, though. I didn’t know it. He told me that he had something but he wouldn’t say. He said, ‘If you want to die, die with me then go ahead and use that needle.’ I didn’t know what he meant by that. I guessed that’s what he meant after I got sick. I didn’t really care either. I just wanted to get high. Didn’t really care about anything…Just didn’t care. ‘Cause of our life, we grew up. The way we grew up and stuff. Didn’t have no parents so we just didn’t care. I just didn’t care.   94   Managing emotional pain was likewise more important to Jane than taking precautions to avoid contracting HIV and HCV. Jane became HCV positive in her early 20s, when the heroin addiction caused by her emotional pain and need to self-medicate was at its peak. She explained that the urgency of getting high to quell her withdrawals from heroin caused her to take the risk of needle-sharing and ultimately become infected with HCV:   So about the hepatitis C. I was in the alley. And, had like 8 rigs and they were all, like plugged, right? And I was trying to get this smashed into me. And my street sisters came by. And I was like, ‘Do you have a rig? Do you have a rig?' And she's like, ‘I just got dirty ones.' And I said, ‘I don't care'. And she said, ‘I'm not gonna fuckin' give you my dirty needles.' And was like, ‘Fucking give it to me!' right? Like, fucking, you know? There was no services at that time. Like, open that late, and it was like 3 or 4 in the morning or something like that. So, and, uh, so she gave me a rig. So, I knew exactly, like, what I was getting into before, but I wanted my drugs that bad, right? So I gave myself hep C For a smash.  Some participants’ stories about injection drug use segued into stories about how they came to be involved in sex work. Two of the male participants in the study and fourteen of the female participants had been involved in sex work. The ages at which they began sex work ranged from 12 to 19 and their primary motivation was to buy drugs and continue to self-medicate, or to provide drugs for their romantic partners. However, continuing involvement in sex work was also associated with negative self-beliefs that had developed as a result of childhood trauma. Jane believed that the damaged identity she had constructed due to her childhood abuse had contributed to her involvement in sex work on the streets:  Building someone with low self-esteem. Taking someone’s self-worth away. Me and my sister both ended up on the streets. There’s got to be a connection there I think.    95 The connection between emotional pain and needing to make money from sex work was also part of Chloe’s story. Chloe had endured years of physical abuse, sexual abuse, and neglect as a child and miscarried a child in her early teens. She explained that the desire to self-medicate gradually led to her involvement in sex work:  Um, I started using drugs, um. Um, I lost a child very young. And um, I started drinking a lot. And then going to the bars. And I was introduced to cocaine in the bar washrooms. And then after bar parties, smoking crack. And then I would be, you know, every couple of months me and a couple of friends would have a night. Then it became every month, then every week, and (laughs) then it just progressed. And then, uh, when, when it was, I wanted to do it more than I could afford it, I had to find a some way to substitute my income to, so I started working the street….Did unbelievable things because of heroin. Um, yeah, I just, just constantly all I wanted to do was drugs. That was my whole, my whole life was hurting myself. It just became my whole life.   Although participants’ desire to self-medicate was understandable, they all expressed the desire to find safer and healthier ways to cope with stress and trauma-related pain. Unfortunately, many explained that they continued using drugs to self-medicate because there were no viable or effective alternatives. This was the current predicament for most participants at the time of their in-depth interview. For instance, Kyle explained that he continued to smoke and inject cocaine in order to deal with upsetting feelings and memories related to being sexually abused by his father:   I mean, I, I mean I would love to stay away from the rock but it’s just something in it that numbs me from feeling, I guess, is the right words to say. To feeling. I don’t know why…when I stop using for a certain amount of time then these emotions come back that I didn’t want there. You know? I mean I know the cocaine isn’t going to make it go away permanently. I know it’s just a temporary solution but it’s temporary and that fits me for now. Because I don’t want those old childhood feelings and those old habits to come back to me again.      96 Understanding family pain and the role of intergenerational trauma  Becoming aware of the intergenerational impacts of the residential school system had a healing effect that helped some participants to better understand their families and themselves. As such, it constituted a stress-coping mechanism that helped them to come to terms with their circumstances, experiences and identities. Seventeen participants were aware that one or more of their parents had attended residential school, thirteen knew that one or more of their grandparents had attended, and seven were unsure about whether any of their family members had attended.   Half of the participants who knew their parents or grandparents had attended residential schools said that they had been told “brutal stories” about abuses at the schools that included instances of corporal punishment with sharp or blunt objects; sexually abuse; witnessing sexual abuse; being violently punished for speaking traditional languages or engaging in traditional spiritual practices, and; being separated from family and community for long periods of time. These participants had come to recognize that the horrific emotional and psychological impacts of their parents’ and grandparents’ residential school experiences had caused substance use and violence or neglect at home. For example, Sarah’s grandmother had attended residential school and had subsequently been emotionally abusive toward Sarah’s mother. Sarah thought that her own mother’s aversion to showing affection and love might be related to the way in which her mother had been parented by her grandmother. Connor likewise acknowledged the legacy of the residential school system. Both of his parents had attended and he understood that it subsequently caused them to struggle with alcoholism and be extremely violent towards each other as well as their children:  (Mom) said that it was bad. And guys abused her lots. Like, the, the fathers in the schools there. They always abused my mom. She’s telling me that part and that’s why, the reason why she was drinking all the time, she said. I don’t   97 know. Kind of sick. It’s probably why she was always drunk all the time ‘cause she didn’t like the way those people was treating her. My dad, too. He said that they used to beat him up all the time. Strap him lots. Whip his hands and stuff. They used to treat them kids rough. They used to treat my dad and my mom real bad in that schools. That’s all I know.  Importantly, eight participants who knew that their parents and/or grandparents were residential school survivors they did not know (or could only guess) what their parents’/grandparents’ experiences were at the schools and how their parents/grandparents had been affected. Some of those participants explained that they had considered the subject of residential schools to be off-limits because it was so sensitive, while others did not feel they had a close enough relationship with their parents to ask them about it. All of these participants were unclear about the intergenerational and direct familial impacts of the residential school system. For instance, Cam knew that his father and aunties had been in residential school but said:  Nobody talked about it. I don’t know if that’s one of the reasons why (father) drank so much. I don’t know.  Some participants had learned about residential schools at community events, through their interactions with Elders, and from the media. For example, Kyle had learned about residential schools at the Native Friendship Centre in Vancouver. He explained how this led to a shift in his perspective of his father and helped him to understand why his father had hurt him:  I didn’t realize and understand that ‘til I was an adult, myself. So I don’t really blame my parents or my, my dad for the way that he was when I was a kid because there was nothing that he could do about it.   Helen also learned about the effects of the residential school system through a community event – a knowledge-sharing event at her reserve community that had been facilitated by the Aboriginal Healing Foundation. Helen’s father had since opened up to her   98 about the experiences both he and his parents had had at residential school, which helped her to understand the intergenerational effects of trauma:  My father, um, because of him being raised in the residential schools from, taken as a child and never being able to see his family and everything and the priests and nuns were like his parents and learned behaviours and them beating him and, you know, he was even raped but my dad never touched me that way, thank God. But he beat us a lot. It started, once it started it didn’t stop. I mean it started and it, it was it became over one dirty dish, like, I had to do the whole load of dishes again to one minute after curfew to, um, bad grades to whatever, like, they’re simple little things and it was bad, I mean. …I know he done that because that, that’s how he felt was his way of teaching us that was wrong and, this is wrong, whatever. He didn’t know how to verbalize it to us cause he didn’t know any better, right? So, you know, ‘cause he was beat up a lot by his dad, I know.  In general, hearing their parent’s and grandparent’s stories of residential school trauma gave participants a context in which to understand and their own experiences of abuse and neglect. For example, Kyle understood that his father’s abusiveness toward him when he was a child was related to intergenerational trauma, and while the information helped him understand why he was abused, he continued to maintain physical and emotional distance from his father. Other participants likewise understood that intergenerational trauma had damaged their parents’ abilities to build trusting relationships with them and accepted that their parents were unable to give them support. Consequently, they did not seek the support of their parents and avoided having close relationships with their family members who were not safe.  4.8.5 Healing  The final theme that emerged in participants’ interviews was a need for healing. Although understanding intergenerational trauma and the impacts of the residential school system helped participants to heal to a certain extent, they felt a particular need for access to more resources that would facilitate greater healing.    99 Some participants’ referred to mental-health related resources when they reflected on healing. Only three participants in this study had accessed professional counseling  that addressed trauma, and only one had received long-term counseling  with an in-depth focus on childhood abuse experiences. Six participants had accessed emergency room care during mental health crises or had been in a psychiatric institution for acute mental health issues, but none of those participants had received any outpatient counseling  or support. Eight participants had tried alcohol and drug counseling  in the past, but only for short periods of time, and their counsellors had not addressed childhood trauma.  The majority of the young people in this study who had not received any trauma counseling  had mixed feelings about the idea of accessing therapeutic resources. Half believed that they should be able to handle their pain independently, without help. These participants did not trust mental health services and therefore believed that trauma counseling  would be unnecessary, unhelpful, or result in their being told they were “crazy”. The majority of participants who had accessed counselling  felt disappointed and unsafe about their experiences because their counsellor was insincere, they could not relate to their counsellor, or they did not have enough sessions to feel comfortable opening up about sensitive topics. Graham stated that:  I mean, if I start seeing a counselor the first thoughts that start going through my mind when I sit down with them is, is this person going to stay long? Are they going to actually listen, or? I start questioning myself about telling them how I feel.  The expectation that participants would abstain from drug use while they accessed trauma counseling  was a significant obstacle. Participants dreaded having to live without self-medication as painful memories and emotions surfaced during counseling . As Sarah explained:    100 I have to get everything out, I guess. ‘Cause counselors, I don’t know, they were, but you know, I’d leave the office with, like, these open wounds and especially if I have money, of course I’m going to go, go to where I know for comfort, right? So, (crying) I don’t want to use anymore.  4.9 Discussion The triangulation performed for this qualitative inquiry into the experiences of childhood trauma and subsequent HIV risk among young Indigenous people who use drugs has validated the causal assumptions made by researchers who conducted various quantitative studies (Craib, Spittal, Patel, Christian, Moniruzzaman, Pearce, Demerais, Sherlock, & Schechter, 2009; For the Cedar Project Partnership et al., 2008). However, it has also provided critical information that has not previously been put forth. In particular, the narratives we examined validated assumptions about the impact that intergenerational trauma has had on HIV risk among the current generation of young Indigenous people who use drugs. In so doing, the narratives support the theoretical perspective that supports the call for historically knowledgeable stand points on family violence among Indigenous peoples.  The young Indigenous people who shared their life stories in this study described complex and harrowing experiences of childhood abuse and neglect that had severe emotional and psychological impacts on their self-conceptions and capacity to cope with stress. They described how alcohol and drug use, the child welfare system, long-term or permanent displacement from their families, and family breakdown manifested in all dimensions of their lives. These aggregated experiences contributed fundamentally to their current vulnerability to HIV and HCV via the pathways of self-medication and self-harm.  Overall, participants’ narratives conveyed three overarching messages or key findings: 1) lifetime experiences of trauma and betrayal have caused deep emotional and psychological   101 barriers to help seeking and healing; 2) the emotional and psychological pain related to childhood trauma and separation from family is a critical and largely unaddressed reality that continues to influence HIV and HCV vulnerability and; 3) understanding the impacts of intergenerational trauma and the residential school system on family relationships is essential to healing. The final message is of particular salience because it indicates that contextualizing their childhood in a meaningful way had a healing effect for participants and as such, might help to reduce their vulnerability to HIV and HCV infection. Trauma and betrayal as barriers to help seeking and healing The first message is informed by the definition of betrayal developed by researchers in the field of childhood trauma: “the dynamic by which children discover that someone on whom they were vitally dependent had caused them harm” or children’s realization “that someone whom they loved or whose affection was important to them treated them with callous disregard” (Finkelhor & Browne, 1985, p. 531). In this research the definition of betrayal must be extended to include being harmed by institutions and care-givers who have failed to provide safety or facilitate healing. Participants in the study described three types of betrayal: the betrayal of individuals who had inflicted harm upon them or who had failed to protect them from harm; the betrayal of individuals who failed to provide them with safety after they disclosed experiences of abuse, and; the betrayal of the child welfare system and therapeutic service providers, which failed to reunify families or provide meaningful resources for healing. Each type of betrayal had profound effects on participants’ relationships with their families and combined to amplify feelings of loneliness and isolation and diminish openness to rely on resources or individuals or help.    102 This message has critical implications for public health and therapeutic service providers. Previous quantitative research has emphasized that the effects of betrayal to include anger, a mistrust of authorities, attachment disorder, and psychological symptoms and pathologies (i.e. depression and post-traumatic stress disorder) (Finkelhor & Browne, 1985; Martin, Cromer, Deprince, & Freyd, 2013). The participants in this study explained that feelings of betrayal represented a significant barrier to maintaining family relationships and seeking health and/or therapeutic services. The vast majority of participants in this study had been abused by family members or by people who had been placed in highly trusted positions, including foster parents. This is consistent with previous Cedar Project research that has demonstrated that among the 48% of participants who reported sexual abuse in their baseline interview, the majority were assaulted by male relatives, the median age of first experience was 6 years old, only 27% had ever told anyone before, and only 35% had ever sought counseling for the abuse (Cedar Project et al., 2008). In this study, many participants were aware that the residential school system had betrayed their parents and grandparents and felt that the child welfare system had betrayed them and their siblings. Public health interventions and mental health services serving young Indigenous people who use drugs must therefore be cognizant of the effects that betrayals have had on their emotional coping abilities and capacity to trust individuals in positions of power or authority (Hildyard & Wolfe, 2002). To support the healing of young Indigenous people who use drugs, it is essential for them to receive care that is culturally safe (Brascoupé & Waters, 2009), trauma-informed (Amaro et al., 2007; Hien, Campbell, et al., 2010), and builds trust-based relationships. Interactive case management approaches are an example of innovative interventions have effectively built trust-based relationships between healthcare providers and people who use illicit drugs. The approaches have focused on secure long-term housing and the   103 provision of supportive counseling, drug treatment, and health care (Thompson et al., 1998). In so doing, they have promoted the self-efficacy of people who use drugs. To promote the self-efficacy of urban Indigenous young people who use drugs, programmers must allow them to be meaningfully involved in each stage of decision-making and program implementation as well as meet Indigenous ethical standards.  104 Unaddressed emotional and psychological pain and HIV/HCV vulnerability  The second key message conveyed by participants’ narratives was that the emotional and psychological pain related to childhood trauma and separation from family is a critical and largely unaddressed reality that continues to influence HIV and HCV vulnerability. A large number of both quantitative and qualitative studies have delineated the pathways between childhood trauma and HIV risk for Indigenous and non-Indigenous people who use drugs (Brown et al., 2014; Clum et al., 2009; Kang et al., 2002; Simoni et al., 2004; Walters & Simoni, 1999; Zierler et al., 1991). Participants’ narratives about the effects of the child welfare system highlighted the additional trauma of having been separated from family, which constituted a unique dimension of the grief that exacerbates vulnerability to HIV infection. The narratives affirmed the view of many Indigenous leaders and scholars who perceive the child welfare system in Canada to have supplanted the residential school system as a means to dismantle Indigenous families and ways of life (Kirmayer et al., 2003). Participants’ HIV and HCV risk was described within the context of life-long efforts to cope with the negative self-concepts, emotions, and memories associated with childhood trauma and separation from families. These efforts began with the avoidance technique of emotional/physical distancing and later escalated into heavy drinking and drug use for self-medication. Participants felt an urgent need to “numb” their thoughts and feelings, regardless of whether it put them at risk of HIV and HCV infection. This need created a quandary for the participants: receiving therapeutic help required them to abstain from drug use, but the thoughts and feelings that surfaced in therapy would exacerbate their need to self-medicate. Self-medication was therefore a barrier to accessing therapeutic help. This speaks to the need for integrated substance use and trauma programming and affirms research that recommends gender-  105 specific, culturally-safe, and low-threshold interventions for people who use drugs that include trauma-informed programming (Amaro et al., 2007; British Columbia Centre of Excellence for Women's Health, 2009; Hien, Jiang, et al., 2010; Smye, Browne, Varcoe, & Josewski, 2011). In addition, such interventions must be long-term, based on the principles of harm reduction, and consistently delivered in order to establish safety and trust. However, most of the harm reduction services in BC that aspire to address such barriers – especially those in the north of the province– subsist on limited budgets and do not usually provide integrated substance use and trauma programming. Understanding intergenerational trauma is essential to healing The third overarching message that emerged from participants’ narratives was that understanding the impacts of intergenerational trauma and the residential school system on family relationships is essential to healing. Gaining this understanding was mitigating and instrumental in helping participants to gain perspective of their own trauma and its consequences. As a result, participants were able to situate themselves within the larger context of the historical injustice and intergenerational trauma experienced by Indigenous peoples in Canada as a whole. This in turn enabled them to shift blame away from their families, identify the systems and institutions that had had destructive impacts on Indigenous parenting styles and family functioning, and begin to restore their pride in their cultural identities.  However, a number of participants who knew that their parents and/or grandparents had been in the residential school system remained unaware of what happened to these family members in the schools and how those experiences may have affected them. Those participants were not afforded the same contextual understanding of intergenerational trauma as the participants mentioned above and consequently did not benefit from its potentially mitigating   106 influence on their anger and resentment towards their families. Goodkind et al. (2012) discussed the seemingly intentional lack of communication about the effects of intergenerational trauma between Indigenous young people and their families because the subject may be too difficult and painful. The researchers suggested that bridging this communication gap would support the development of traditional coping mechanisms and “promote collective healing” (p. 1033). For young urban Indigenous people who use drugs and are often disconnected from their families, bridging the gap will require the support of community-based programs that facilitate safe and meaningful conversations about historical and intergenerational trauma. For example, the culturally-based therapeutic programs offered by Native Friendship Centres and the Aboriginal Healing Foundation have been critical to strengthening communication and awareness among Indigenous families. Further, facilitating programs that explicate the parallels between the residential school and child welfare systems – including long-term separations from parents, feelings of powerlessness, isolation, and loneliness, and the lack of strong cultural identity and coping skills – may help young Indigenous people who use drugs to reduce self-blame and develop a compassionate perspective that motivates them to heal (