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HIV/STI stigma, gender, and young people Karamouzian, Mohammad 2016

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HIV/STI STIGMA, GENDER, AND YOUNG PEOPLE by  Mohammad Karamouzian  D.V.M., Shahid Bahonar University of Kerman, 2010  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Population and Public Health)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  June 2016  © Mohammad Karamouzian, 2016 ii  Abstract Background: In the context of HIV/STI, there is a large and growing body of literature assessing stigma. However, most studies have concentrated on adult populations, leaving several aspects of HIV/STI-related stigma amongst young people open to question. The current thesis examines the issue of HIV/STI-related stigma on young people’s sexual health. Methods: To examine the potential influence of stigma on STI testing amongst marginalized youth, data from the At-Risk Youth Study (ARYS) was used to examine the influence of stigma on STI testing uptake amongst 300 street-involved young people. To explore young people’s perceptions about the capacity for stigma to be mitigated using online testing approaches, individual, semi-structured interviews were completed with 71 young people and analyzed thematically. Moreover, to characterize the state of the literature regarding HIV-related stigma amongst youth living with HIV (YLHIV), a systematic search of the literature was used to identify 22 studies measuring HIV-related stigma among YLHIV; each study was evaluated to assess how sex or gender considerations were taken into account. Results: Perceived devaluation, was independently associated with decreased STI testing uptake among street-involved youth. Moreover, the qualitative analysis pointed to the potential benefits of online HIV/STI testing for reducing the external stigma, despite the complexities around addressing internalized notions of HIV/STI-related stigma among youth as well as the gendered experiences of HIV/STI-related stigma in online testing environments. Among the 22 papers included in the systematic review, several gaps were identified in the existing literature of HIV-related stigma including the missing accounts of sex or gender on HIV-related stigma among YLHIV. Conclusions: Taken together, the findings of the current thesis suggest that HIV/STI-related iii  stigma affect youth’s sexual health care seeking practices in both online and clinic-based settings – and that experiences may differ by gender. To combat HIV/STI-related stigma and its effects, it will be necessary to address underlying individual- and structural-level factors, including gender stereotypes.  However, the current literature does not appear to fully account for youth’s gendered experiences, leaving many interventions to promote youth sexual health insufficiently informed and offering space for new research to address an important theoretical and practice gap.   iv  Preface Work for this thesis was conducted using data from an ongoing study (ARYS) supported by the US National Institutes of Health (R01DA028532, U01DA038886) and the Canadian Institutes of Health Research (MOP–102742), a qualitative data repository (OSTY) based at the Youth Sexual Health Team, and a systematic review. All data pertaining to the quantitative and qualitative analysis of chapters two and three were collected, cleaned, and coded previously by staff at the BC Centre for Excellence in HIV/AIDS and the Youth Sexual Health Team, respectively. These studies have been approved by the University of British Columbia/Providence Health Care Ethics Board (ARYS: H04-50160; OSTY: MOP-106440). With the guidance and assistance of my supervising committee (Dr. Jean Shoveller, Dr. Mark Gilbert, and Dr. Thomas Kerr), I conceptualized the empirical research designs (Chapters two and three) and the systematic review (Chapter four) chapters. I conducted the analysis of chapters two and three as well as the review chapter. For chapter one, I worked closely with statisticians from the BC Centre for Excellence in HIV/AIDS to develop a data analysis plan, which was carried out by them using SAS. I created all tables and figures using Microsoft Word or Microsoft Excel. Co-author Dr. Rod Knight contributed to the qualitative analysis of chapter three.  A version of Chapter two, three, and four are currently undergoing co-author revision, and will be submitted for publication in the upcoming months.  v  Table of Contents  Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iv Table of Contents ...........................................................................................................................v List of Tables .............................................................................................................................. viii List of Figures ............................................................................................................................... ix List of Abbreviations .....................................................................................................................x Acknowledgements ..................................................................................................................... xii Dedication ................................................................................................................................... xiv Chapter 1: Study Background, Rationale, and Objectives ........................................................1 1.1 Background ..................................................................................................................... 1 1.1.1 Health-related Stigma ................................................................................................. 1 1.1.2 HIV-related Stigma as Structural and Relational ........................................................ 2 1.1.3 Internalized, Enacted, Anticipated, and Perceived Stigma: Health Effects ................ 3 1.1.4 Intersecting Forms of Social Marginalization and HIV-related Stigma ..................... 4 1.1.5 Layered and Intersecting Stigmas ............................................................................... 5 1.1.6 HIV-related Stigma and Gender ................................................................................. 6 1.1.7 Sexual and Reproductive Health-related Stigma and Youth ...................................... 7 1.1.8 HIV-related Stigma and Youth ................................................................................... 8 1.1.9    Rationale ..................................................................................................................... 8 1.1.10 Thesis Objectives and Overview of Thesis Chapters ................................................. 9  vi  Chapter 2: Perceived Devaluation and STI Testing Uptake among a Cohort of Street-involved Youth in a Canadian Setting .......................................................................................11 2.1 Introduction ................................................................................................................... 11 2.2 Methods......................................................................................................................... 13 2.2.1 Study Design and Population .................................................................................... 13 2.2.2 Study Variables ......................................................................................................... 13 2.2.3 Data Analysis ............................................................................................................ 15 2.3 Results ........................................................................................................................... 16 2.4 Discussion ..................................................................................................................... 17 2.4.1 Conclusions ............................................................................................................... 20 Chapter 3: Stigma Associated with STI Testing in an Online Testing Environment: Examining the Perspectives of Youth in Vancouver, Canada .................................................25 3.1 Introduction ................................................................................................................... 25 3.2 Methods......................................................................................................................... 27 3.2.1 Study Setting ............................................................................................................. 27 3.2.2 Sampling/Recruitment .............................................................................................. 29 3.2.3 In-depth Individual Interviews .................................................................................. 29 3.2.4 Data Analysis ............................................................................................................ 30 3.3 Results ........................................................................................................................... 31 3.3.1 Study Participants ..................................................................................................... 31 3.3.2 Online STI Testing and Perceptions of Stigma......................................................... 32     Neutralizing External Stigma .................................................................... 32     Persistence of Internalized Stigma ............................................................ 35 vii     Gender Stereotypes ................................................................................... 37 3.4 Discussion ..................................................................................................................... 39 3.4.1 Conclusions ............................................................................................................... 41 Chapter 4: An Analysis of Measures Used to Assess HIV-related Stigma among Young People Living with HIV: Missing Accounts of Sex and Gender ..............................................45 4.1 Introduction ................................................................................................................... 45 4.2 Methods......................................................................................................................... 46 4.2.1 Search Strategy ......................................................................................................... 46 4.2.1 Inclusion and Exclusion Criteria ............................................................................... 47 4.2.1 Data Analysis ............................................................................................................ 47 4.3 Results ........................................................................................................................... 48 4.3.1 Characteristics of Included Studies ........................................................................... 48 4.3.2 Sex/Gender Analysis ................................................................................................. 49 4.4 Discussion ..................................................................................................................... 50 4.4.1 Strength and Limitations .............................................................................................. 51 4.4.2 Conclusions .................................................................................................................. 52 Chapter 5: Summary of Findings, Implications for Policy and Research ..............................57 5.1 Summary of Findings .................................................................................................... 57 5.2 Implications for Research and Policy ........................................................................... 59 5.2 Conclusions ................................................................................................................... 60 Bibliography .................................................................................................................................62 Appendix A ...................................................................................................................................71 viii  List of Tables Table 1.1: Conceptual Definition of Different Types of Stigma……………..………………….10 Table 2.1: Baseline Sample Characteristics Stratified by STI Testing Uptake in the Previous Six Months among Street-involved Youth in Vancouver, Canada ..................................................... 22 Table 2.2: Univariable and Multivariable GEE Analyses of Factors Associated with STI Testing Uptake among Street-involved Youth in Vancouver, Canada ...................................................... 24 Table 3.1: Socio-demographic Characteristics of the Youth in a Qualitative Assessment of STI-related Stigma, Vancouver, Canada .............................................................................................. 44 Table 4.1: Characteristics of studies measuring HIV-related stigma among youth living with HIV (YLHIV) ....................................................................................................................................... 54      ix  List of Figures Figure 3.1: Illustration Describing the GCO Testing Service as Presented to Participants .......... 43 Figure 4.1: Study Inclusion Flowchart for Papers Measuring HIV-related Stigma among Youth Living with HIV ............................................................................................................................ 53  x  List of Abbreviations AIDS: Acquired Immuno-Deficiency Syndrome AOR: Adjusted Odds Ratio ART: Antiretroviral Therapy ARYS: At Risk Youth Study BC: British Columbia CESD: Center for Epidemiologic Studies Depression Scale CI: Confidence Interval CT: Chlamydia trachomatis DTES: Downtown Eastside FSWs: Female Sex Workers GC: Neisseria gonorrhoeae GCO: Get Checked Online GEE: Generalized Estimating Equation HCV: Hepatitis C virus HIV: Human Immunodeficiency Virus IQR: Interquartile Range LGBTT: Lesbian/Gay/Bisexual/Transvestite/Transsexual MSM: Men who have Sex with Men OR: Odds Ratio PLHIV: People Living with HIV PWID: People Who Inject Drugs  PWUD: People Who Use Drugs xi  STI: Sexually Transmitted Infections YLHIV: Youth Living with HIV xii  Acknowledgements I would like to sincerely thank my supervisor Dr. Jean Shoveller and my supervisory committee, Drs. Mark Gilbert and Thomas Kerr for their patience, generosity, support, and invaluable wisdom. Your support and confidence have continually motivated me to set higher goals for myself. I look forward to continuing my training under your supervision. A very special thanks goes to Dr. Shoveller, who has guided me through every difficult decision-making process I have encountered in the past few years and has been a true mentor for my personal and professional life.  I would also like to thank my colleagues and friends at youth sexual health team whose door was always open to discuss thoughts, provide helpful guidance, and share a laugh. Thank you Anna, Cathy, Rod, Michelle, Caroline, Taylor, Devon, Jonathan, Basia, and Andrea.  This work would not have been possible without the data collected by the BC Centre for Excellence (BC CfE) faculty and staff At Risk Youth Study (chapter 1) and Youth Sexual Health Team (chapter 3). I am also very grateful to Dr. Kora DeBeck for her valuable input to the data analysis plan of chapter one. I would also like to extend my sincere gratitude to BC CfE statisticians Sabina Dobrer and Huiru Dong for all of their help and patience throughout this process of data analysis for chapter two. Interviews of chapter three were conducted by Wendy Davis. In the School of Population and Public Health, I would particularly like to thank Beth Hensler, who went above and beyond administration, and became a very good friend. xiii  Last but not least, a very special thank you to my parents (Ahmad and Mahin), brothers (Ehsan and Iman), sister-in-law (Elnaz) and two best friends (Angeli and Celestin) for your unconditional love and support.  My Masters training was generously supported by funding provided by Ann and William Messenger Graduate Fellowship, Northern Telecom Graduate Fellowship, Shaughnessy Hospital Volunteer Society Fellowship in Health Care, and research assistance support from UBC’s Youth Sexual Health Team. xiv  Dedication To the memory of my grandmother (Robabeh) and cousin (Parinaz) who passed away while I was away from home.   1  Chapter 1: Study Background, Rationale, and Objectives 1.1 Background 1.1.1 Health-related Stigma Early stigma theorists, including Erving Goffman, describe stigmatization as a process by where the stigmatized person is reduced “from a whole and usual person to a tainted, discounted one” (1, 2). Building on Goffman’s work regarding the “deeply discrediting” power of stigma, Link and Phelan asserted that stigmatization is inherently a social process involving stereotyping, labelling, and status loss. They theorized that these social processes contribute to social inequalities between those who are stigmatized and those who are the stigmatizers (3). Their framework describes stigma as a combination of labelling based on differences, linking the labeled groups to unpleasant characteristics, separating ‘them’ from ‘us’ by placing ‘them’ in undesirable categories (3). Furthermore, stigmatized people and groups experience loss of status and are forced to see themselves as ‘others’ who are marked by blemished characters and “abominations of the body” (2, 4). In recent years, the notion of stigma has received increasing attention, particularly with regard to the ways in which stigma may contribute to the individual- and population-level burden of diseases and access to public health programs as well as health care services. Stigma has been linked with increased levels of psychosocial suffering associated with several chronic health conditions and with delays in the diagnosis and treatment of infectious diseases (5, 6). In the case of sexually transmitted infections (STI) in particular, stigma has been associated with a continuation of risky behaviour and failed preventive interventions (7, 8), contributing to the onwards transmission of STI. In people infected with STI, stigma also has been linked to poor treatment adherence (9). 2  1.1.2 HIV-related Stigma as Structural and Relational In their writings on HIV-related stigma, Parker and Aggleton also conceptualize stigma as a social process; but, they extend the argument put forward by Link and Phelan by suggesting that stigma also is attributable to power relations and cultural norms. Their work highlights the importance of stigma as a sociocultural phenomenon embedded in contexts of families, neighbourhoods, and communities (10). Stigmatization in their view is dialectically connected with power relations and social inequalities. They draw attention to stigma producers and underscore the importance of viewing stigma and resultant acts of discrimination at a structural and institutional level (10). These conceptualizations of HIV-related stigma are important for understanding the interplay between structural and interpersonal drivers of HIV. For example, structural drivers of HIV-related stigma, including laws and policies that disadvantage people living with HIV (PLHIV), intersect with interpersonal factors, such as stigmatizing opinions and actions against PLHIV. A structural and relational conceptualization of HIV-related stigma illuminates distinctions between ‘non-stigmatized’ and ‘stigmatized’ groups and reveals the mechanisms by which prejudice, stereotyping, and discrimination against stigmatized groups are realized (11-17).  HIV-related stigma has been associated with patterns of social rejection, and exclusionary and physical distancing practices; or, in more extreme cases, it has encompassed violence and physical harm (18, 19). While most studies of HIV-related stigma have focused on forms of social rejections experienced by PLHIV, some research also has demonstrated how HIV-related stigma contributes to reduced test seeking practices and risk disassociation amongst highly stigmatized groups (e.g., gay men; people who inject drugs; sex workers) (20, 21).   3  1.1.3 Internalized, Enacted, Anticipated, and Perceived Stigma: Health Effects  Experiences of HIV-related stigma by PLHIV include internalized stigma, enacted stigma, anticipated stigma, and perceived stigma (11) (Table 1.1.). A plethora of evidence indicates that HIV-related stigma negatively affects the health of PLHIV. Internalized, or self-stigma, is characterized by self-endorsed negative beliefs and emotions attributed to HIV (3, 22). HIV self-stigma is associated with several outcomes including, depression (23-25), anxiety (26), feelings of shame (27), psychological distress (22), as well as lower levels of hope about the future (26), reduced self-esteem (23), lack of sense of personal control (28), and increases in self-reported physical symptoms associated with HIV (24). Furthermore, self-stigma has been associated with lower social support (23, 24, 27), poorer social integration, greater social conflict (23), and lower quality of life among PLHIV (29). Recent diagnosis of HIV, less supportive families/communities, and knowing fewer PLHIV in one’s social networks have been associated with higher levels of internalized stigma among PLHIV (26). Receiving antiretroviral therapy (ART), counselling, and normalization of HIV infection have been attributed to lower levels of internalized stigma among PLHIV across different cultural contexts (30).  Enacted stigma (i.e., stigma characterized by ‘actual’ experiences of prejudice, stereotyping or discrimination from others) can also lead to adverse outcomes among PLHIV, which may vary in intensity and content across various sociocultural contexts (11). Among PLHIV, enacted stigma has been associated with poorer mental health (27), self-esteem (23), depression (23), self-blame (31), shame (27, 32), physical HIV symptoms (29), and lower adherence to ART (33). Like internalized HIV-related stigma, enacted stigma negatively affects PLHIV’s social spheres and is associated with lower social support (23, 27), social isolation (23, 32) and social conflict (23). 4  Anticipated stigma (i.e., expectations or fears that an individual will experience prejudice, stereotyping or discrimination from others) and perceived stigma (i.e., the perception of the prevalence of stigmatizing attitudes in the community) are two types of stigma that are sometimes used interchangeably in the HIV-related stigma literature (34, 35); however, they are different. Anticipated and perceived stigmas have received less attention in the empirical HIV-related stigma research than have enacted or internalized stigma. However, the available evidence indicates that they are associated with lower social support and mental health (23, 36), as well as psychological distress and physical illness (37) among PLHIV. Anticipated and perceived stigmas are also associated negatively with the likelihood of disclosing HIV status (31, 38-40). 1.1.4 Intersecting Forms of Social Marginalization and HIV-related Stigma Stigmatizing behaviours directed at PLHIV have been linked with ignorance and misunderstanding about HIV infection on the part of the stigmatizers (11). HIV-related stigma also has been shown to be compounded by other forms of social marginalization (10, 11, 41). A considerable portion of PLHIV belong to marginalized subgroups who already experience other forms of stigma associated with racism, ageism, or biases rooted in gender or sexual identities (e.g., transwomen) (42), as well as stigmatized behaviours (e.g., drug use). Women living with HIV have been shown to experience higher levels of social isolation and depression (42) and young PLHIV have been shown to experience higher levels of anticipated or enacted stigma that experienced by older PLHIV (43). In a study that compared stigma scores across different ethnicities, Black men and women reported significantly higher total stigma scores than White men and women (44). 5  1.1.5 Layered and Intersecting Stigmas Highly marginalized population subgroups such as, female sex workers (FSWs), men who have sex with men (MSM), and people who inject drugs (PWID), have also been shown to experience multiple and intersecting stigmas (42, 45). Multiple stigmas experienced by PLHIV have been conceptualized in two primary ways (46): (1) as layered stigma, which suggests that HIV-related stigma is ‘added’ to other types of stigmas experienced by PLHIV (45); and (2) as intersectional stigma, which argues that HIV-related stigma synergistically and multiplicatively intersects with other types of stigma experienced by PLHIV (45, 47).  Layered models of stigma have been critiqued for their inability to fulsomely capture the complexities of how PLHIV experience multiple stigmas (46) and for tacitly creating hierarchies of stigma, whereby some stigmas (e.g., HIV-related stigma) are positioned as more important than others (e.g., racism) (47). Intersectional stigma has been described by Berger (47) as “the interlocking forms of oppression which can be identified as separate, singular systems, but whose explanatory power is greatly enhanced when they are seen as interactive and interdependent on each other.” This model allows for the total experienced stigma to exceed the summation of each entity and does not conceptualize stigmas in a hierarchical way. Despite distinctions between these two models, both conceptualizations highlight the importance of multiple stigmas, including HIV-related stigma, on the lives of PLHIV (46).  Gender stereotypes and HIV-related stigma also can be conceptualized as jointly reproduced forms power and control, “linked to competition for power and the legitimization of social hierarchy and inequality” (10). The connections between gender and HIV-related stigma have been most fully examined as socio-cultural representations, which underscore gender hierarchies, which are thought to be internalized and embodied as a stereotypical, ‘natural’ 6  phenomenon (48, 49). Stereotypical gender roles, for example, are viewed as providing a rubric that informs one’s daily interactions with people and which helps to define the ‘proper’ and ‘expected’ behaviour (48, 49) – with deviations from these expectations being highly stigmatized. Mahajan and colleagues (15) and Holzemer and colleagues (29) position gender stereotypes as integral to various forms of stigma (15, 29), including interpersonal stigma and institutional stigma. Interpersonal stigma centers on an individual’s enacted experiences of stigma. Institutional stigma refers to the laws and policies that make explicit discrimination towards stigmatized populations (10, 29).  1.1.6 HIV-related Stigma and Gender In several studies, the combined effects of HIV-related stigma and gender stigma have been shown to inhibit engagement in HIV testing and treatment. For example, Tanzanian women have reported fear of violent reactions and power dynamics inherent to their relationships with men as major barriers to seeking HIV testing (50). Similar concerns have been echoed by Zambian women who concealed their positive HIV status and attempted to hide their use of HIV treatments (51). In a study in 2001 in Uganda, women living with HIV were more likely to experience enacted stigma, especially by their family members (52). Recent studies suggest that women living with HIV continue to be discriminated by their family members, while men are more likely to experience anticipated and internalized stigma due to their perception of how they are viewed by the community (53). Similar findings are also reported in Swaziland, where men living with HIV were more likely to experience internalized stigma while experiences of enacted stigma were more prevalent among women (54). Stigma studies outside Africa also point to differences among men and women living with HIV in terms of experiencing stigma (55). Additionally, HIV-related stigma continues to affect the subpopulation of transgender people. In particular transgender 7  women face complex structural and institutional forms of HIV-related stigma, including social exclusion, economic marginalization, and unmet healthcare needs (56, 57). Transgender women’s experiences of stigma within the public sphere are also linked with higher risk of HIV infection compared to other adult populations (57, 58).  1.1.7 Sexual and Reproductive Health-related Stigma and Youth Ageism is also an expression of stigma. Youth are often viewed as immature individuals who are not ‘ready’ to make the ‘right’ decisions regarding their sexual lives (e.g., timing their first sexual experience; being or not being sexually active; choosing their sexual partners; accessing contraception). Therefore, parents, caretakers, teachers or public health officials are expected to monitor and inform young people’s decision about sexual and reproductive health (59). High levels of stigma directed towards youth who transgress social norms have been shown to result in young people trying to hide their sexual activities and their avoidance of seeking care and treatment for STI (59-61). Decreased uptake of STI testing among youth has been strongly associated with STI stigma (15, 51, 62, 63). Concerns about anonymity and confidentiality, as well as age-based and gendered power dynamics in stigma experienced by young people during clinical examinations and pre/post-test counselling have also been identified as barriers to STI testing among youth (63, 64). Moreover, like other population subgroups, youth are a diverse group whose STI-related stigma experiences may vary due to the concurrent forms of stigma related to gender, race, and socio-economic status (59, 63). For example, experiences of STI-related stigma among youth coming from low socio-economic backgrounds or marginalized ethnicities are often different than those who live in privileged families (43). Gender inequalities also differentially shape young people’s experiences of HIV/STI-related stigma as well as HIV/STI risk behaviour. For example, young men’s sexual prowess and promiscuity are celebrated (despite its concomitant 8  risks), while young women’s sexual behaviour is frequently regarded as socially unacceptable and shameful (59).  1.1.8 HIV-related Stigma and Youth Young people may experience similar HIV-related stigma that adult populations do; but, they do so at a critical time in their social development. Youth affected by or infected with HIV face potentially exacerbated levels stigma (65), often with dire implications (e.g., being rejected or maltreated by family, the broader community and service providers) (65, 66). Several studies have focused on understanding HIV-uninfected youth’s attitudes towards HIV and PLHIV (15, 51, 62, 67), but few have examined their experiences of being stigmatized because of their HIV-status (66). As well, there is growing evidence regarding the associations between HIV-related stigma and decreased uptake of HIV testing among youth (15, 51, 62).  Among youth living with HIV (YLHIV), high rates of alcohol and illicit drug use and risky sexual behaviours render them vulnerable to experiencing additional stigma. Swendeman and colleagues report that 89% of YLHIV anticipated HIV-related stigma from their peers and the community where it was associated with female gender and injection drug use. Moreover, 31% of the participants of their study reported having experienced an incident of enacted HIV-related stigma in the past three months; furthermore, the likelihood of reporting such an incident was linked with identifying as a sexual minority (e.g., gay/bisexual), having symptomatic HIV disease, and sex work (43). These findings indicate that stigmatizing social environments create barriers for effective preventive efforts.   1.1.9 Rationale  Several indicators have been developed to assess HIV- and STI-related stigma – both from the perspectives of the ‘stigmatizers’ (e.g., the general public; healthcare or social service 9  providers) as well as from the perspectives of the ‘stigmatized’ (e.g., PLHIV or people belonging to high risk populations such as FSWs, PWID, and MSM). However, most previous studies on stigma have focused on adult populations, leaving several aspects of HIV/STI-related stigma among youth open to further research. Furthermore, only a few studies have provided insight into the ways in which gender might affect HIV/STI-related stigma amongst young people. Understanding how gender and stigma are intertwined may help us to understand why young men and women have different experiences of HIV/STI-related stigma – which may enable us to integrate a more robust, gender-informed approach to addressing HIV/STI-related stigma. 1.1.10 Thesis Objectives and Overview of Thesis Chapters The current thesis examines youth’s experiences of HIV/STI-related stigma and its impact on their sexual health care seeking practices, through a gender lens. Chapter Two assesses the association of perceived stigma and reduced STI testing practices among a cohort of marginalized street-involved youth. Having identified stigma as a significant barrier to STI testing among youth, Chapter Three examines whether youth’s experiences of stigma, including gender stereotypes associated with HIV/STI testing, would be reproduced in an online HIV/STI testing environment. Furthermore, having observed varying experiences of HIV/STI-related stigma among young men and women, Chapter Four examines how sex or gender has been accounted for within a subset of the peer-reviewed literature that purports to assess HIV-related stigma. Finally, Chapter Five discusses the key findings of the main analyses of the thesis and describes their respective contributions to the literature. The final chapter also discusses potential future research and intervention implications arising from the results of the analyses presented in this thesis.   10   Table 1.1: Stigma: Types, Definitions, and Examples of Measures  Type of stigma  Conceptual Definition Example of Item Used to Measure Experienced/Enacted Stigma that is enacted through interpersonal acts of discrimination e.g., People have physically backed away from me because I have HIV Perceived Perception of the prevalence of stigmatizing attitudes in the community e.g., Most people would not sit next to someone with HIV in public or private transport Anticipated Fear of stigma, whether or not it is actually experienced e.g., Do you think you would be rejected by family if others found out about your HIV status? Internalized/Self Acceptance of experienced or perceived stigma as valid, justified e.g., I sometimes feel worthless because I am HIV Positive Compound/Layered The intersecting of stigmas faced by individuals who are part of multiple marginalized groups e.g., A young street-based female sex worker living with HIV   11  Chapter 2: Perceived Devaluation and STI Testing Practices among a Cohort of Street-involved Youth in a Canadian Setting 2.1 Introduction An estimated 150,000 street-involved youth live in Canada (68), with  Aboriginal, sexual minority, and male youth being at an increased risk of becoming street-involved (68-71). Street-involved youth often experience reduced access to healthcare, and are more likely to experience criminal justice system involvement, food insecurity, homelessness and unstable housing, as well as limited job and education opportunities (71, 72). Studies have shown that up to 95% of street-involved youth have ever used illicit drugs whereas over 40% have ever injected drugs (68, 71, 73-75). In Canada, compared to the general youth population, street-involved youth also are reportedly more likely to be sexually active, have multiple sex partners, experience sexual debut at an earlier age, report low rates of condom use, or engage in sex work (68, 69, 76). Street-involved young people are at elevated risk of sexually transmitted infections (STI). Studies in Canadian cities have observed the prevalence of Chlamydia trachomatis (CT) among street youth to be between 6.6 and 11.1% and Neisseria gonorrhoeae (GC) of up to 6% (76, 77). Moreover, the incidence of both CT and GC among street-involved youth in Canada has been estimated at approximately ten times that of the general young people’s population (68). Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) rates among street-involved youth are also three and six times that of the Canadian adult population, respectively (68).  Street-involved youth are often severely socially marginalized and experience multiple and intersecting stigmas (60, 78) (e.g., social labeling and stereotyping; social and physical separation from the general population; loss of social status; discrimination in a range of sectors, 12  including educational and employment). Many young people are stigmatized through an association with illicit drug use (60, 79, 80). Drug use is often viewed as stigmatized behaviour across various international settings, and people hold negative opinions about Illicit drug users; they are often seen as weak, immoral, and dangerous (79). Experiencing multiple forms of stigma at a critical juncture in their social development, contributes to ongoing perceived devaluation and alienation whereby negative self-perceptions based on the general public’s stereotypes about street-involved youth (or people who use drugs (PWUD) in general) are internalized and reinforced over the life course (79, 81-83). Perceived devaluation (a facet of perceived stigma) refers to “beliefs that members of a stigmatized group have about the prevalence of stigmatizing attitudes and actions in society” and occurs when illicit drug users think that most people believe common negative stereotypes about drug users (81, 84). These attitudes have been shown to have damaging influences on the mental and physical health of PWUD (79, 81, 82, 85) and may persist even after drug use or street involvement is discontinued (81).  Perceived devaluation may also create barriers to health seeking (79-82, 86) and a growing body of literature has documented the association between perceived stigma and health outcomes among adults who use illicit drugs (e.g., heightened stress responses; participation in unhealthy behaviours; nonparticipation in healthy behaviours) (79, 82, 83, 87, 88). The adverse health outcomes associated with perceived stigma could vary across young men and women due to the existing gender inequalities that provide the social context for stigma and often operate through health-related gender differences (48, 49). For example, gender relations influenced by a number of socio-cultural norms and expectations influence young women’s sexual health practices and STI testing uptake (89). Nonetheless, we do not yet fully understand how 13  perceived devaluation may affect the STI testing uptake of young men and women who are street-involved and who are likely to experience other forms of stigmas due to their use of illicit drug use and sexual practices. Therefore, this study examines the whether perceived devaluation is independently associated with reduced STI testing uptake among street-involved youth, and that gender modifies the effect of perceived devaluation on STI testing uptake of street-involved youth.  2.2 Methods 2.2.1 Study Design and Population Data was obtained from the At-Risk Youth Study (ARYS), a prospective cohort study initiated in 2005 among street-involved youth in Vancouver, BC, Canada. Eligibility criteria include individuals aged 14 to 26 who have used illicit drugs other/in addition to marijuana in the last 30 days. Details of the study design and recruitment have been described elsewhere (90). In brief, youth are recruited through snowball and outreach sampling approaches aiming to maximize the representativeness of the sample. Participants complete an interviewer-administered risk assessment questionnaire and provide blood specimens for HIV and HCV serological tests at baseline. The questionnaire includes items on socio-demographics, substance use, sexual and drug-related risky behaviours, encounters with the criminal justice system, and healthcare utilization.  2.2.2 Study Variables The primary outcome of interest in this study was a history of STI testing in the past six months. Participants who reported having been sexually active in the past six months were included in the analysis. The primary outcome of interest was ascertained by examining responses 14  to the following questions: “Have you ever been tested for a sexually transmitted infection (STI) other than HIV?” (If yes) “When was the last time you were tested?”  The primary explanatory variable of interest in this study was a composite measure of one aspect of perceived stigma - perceived devaluation. Perceived devaluation was measured using three statements (i.e., Most people think that someone who uses drugs is reliable; Most people think that someone who uses drugs is a good person; and Most people think that someone who uses drugs is not dangerous) on a 5-point Likert scale, 1 (strongly disagree) to 5 (strongly agree), with summed scores ranging from 3 to 15 and final scores were divided by 3 to reach a mean perceived devaluation score. High scores on the perceived devaluation scale suggest dissatisfaction with self-image, feelings of low self-esteem, and fear of falling short of aspirations and therefore, reflect greater perceptions of devaluation. Mean scores were then categorized into three levels; i) Low (mean score<3) ii) Moderate (mean score=3), and iii) High (mean score>3)(79).  Other independent variables (potential confounders), chosen based on their known or a priori hypothesized relationship with perceived devaluation and STI testing uptake, included age (<19 vs. ≥19), Aboriginal ancestry (yes vs. no), gender (men vs. women), Lesbian/Gay/Bisexual/Transvestite/Transsexual (LGBTT) (yes vs. no), stable relationship (yes [Regular partner, marriage or common law] vs. no [single or non-regular partner or divorced]), and education (<high school vs. ≥high school). Other individual-level factors examined were unprotected sex (yes vs. no), involvement in sex work (yes vs. no), sex with an HIV/STI-infected partner (yes vs. no), multiple sex partners (yes vs. no) and depression at baseline. The presence of depressive symptoms was evaluated based on The Center for Epidemiologic Studies Depression Scale (CES-D) using a clear cut-off (yes [score of ≥22] vs. no [score of <22])(91). Substance-15  related variables included injection drugs use (yes vs. no), non-injection  binge drug use (yes vs. no), binge alcohol use (yes vs. no), accessing drug/alcohol treatment (yes vs. no), daily meth use (yes vs. no), daily cocaine use (yes vs. no), daily heroin use (yes vs. no), daily crack use (yes vs. no), and public drug injection (yes vs. no). Lastly, structural-level variables examined included homelessness (yes vs. no), living in Downtown Eastside (yes vs. no), having warrants/area restriction (yes vs. no), incarceration (yes vs. no), health service utilization (yes [Seen a doctor, nurse or other health professionals] vs. no), and sexual/physical violence (yes vs. no). All behavioural and structural variables pertained to the six months prior to the interview.  2.2.3 Data Analysis Descriptive statistics were used to determine the relevant characteristics of each independent variable as well as the outcome variable (STI testing in the past six months). Univariate categorical data was analyzed using Pearson’s chi-square test and the Fisher’s exact test were used for contingency tables in which 25% or more of the expected cell frequencies are less than five. Interval variables were analyzed using the Wilcoxon rank sum test.  As the analyses of STI testing included serial measures for each participant, generalized estimating equations (GEE) with logit link were used, which provided standard errors adjusted by multiple observations per person using an exchangeable correlation structure. Because the objective of this analysis was to determine whether perceived devaluation, independent of established individual- and macro-level factors, was associated with STI testing, multivariable GEE models were fit using a conservative stepwise backward selection approach (92). All variables that were associated with STI testing uptake in unadjusted analyses at P-value of less than <0.10 were included in a full multivariable model and a stepwise approach was used to fit a series of reduced models. After comparing the value of the coefficient of the perceived devaluation 16  in each reduced model, the secondary variable associated with the smallest relative change were dropped until the minimum change exceeded 5%. Potential modifying effects of gender on the effect of perceived devaluation on STI testing practices was examined by introducing an interaction term to the model. All statistical modelling were conducted using SAS software (SAS, Cary, NC) and all reported P-values are two-sided. 2.3 Results A total of 300 eligible participants were recruited between December 2013 and June 2014. Socio-demographic, behavioural, structural characteristics of the participants at the baseline interview are stratified by STI testing history and presented in Table 1. Participants had a median (IQR) age of 24.5 (21.7-27.4) at baseline. Of the 300 participants interviewed at baseline, most reported a high perceived devaluation score (87%), were of a non-aboriginal ancestry (71.7%), male (63.7%), heterosexual (76.3%), and in unstable relationships (69.3%). In the past six months, most had had unprotected sex (73.3%), were not involved in sex work (87.3%), and did not report multiple sex partners (51.3%). Moreover, 48.7% reported injection drug use, 12.3% shared syringes, and 50.0% accessed drug/alcohol treatment. Regarding structural-level characteristics in the past six months, 35.3% reported public drug injection, 47% reported homelessness, 29.7% had warrant/area restrictions, and 82.7% utilized healthcare services. Compared to those who had tested for STI, those who reported STI testing were more likely to be female (56.8% vs. 27.8%; P-value< 0.001), have been involved in sex work (20.5% vs. 9.4%; P-value= 0.009), have accessed drug/alcohol treatment (64.8% vs. 43.9%; P-value< 0.001), have injected in public (43.2% vs. 32.1%; P-value= 0.057), and have utilized healthcare services (92.0% vs. 78.8%; P-value= 0.006). The crude and adjusted longitudinal estimates of the odds of STI testing being associated with perceived devaluation are presented in Table 2. In the bivariable analysis, perceived 17  devaluation was statistically significant and positively associated with STI testing (ORModerate/Low= 0.23, 95% CI: 0.06–0.82; ORHigh/Low= 0.45, 95% CI: 0.19–1.10). In multivariate analyses, after adjusting for potential confounders including sexual and drug-related variables, perceived devaluation remained independently associated with STI testing (AORModerate/Low= 0.28, 95% CI: 0.07–1.16; AORHigh/Low= 0.38, 95% CI: 0.15–0.98). Other variables that remained significant in the multivariable analysis were female gender, multiple sex partners, and accessing drug/alcohol treatment. In a sub-analysis to check the model selection process, several variables were forced into the multivariable model (e.g., being in a stable relationship, LGBTT status, and depression) to reflect their hypothesized confounding effects; however, the main estimates remained unchanged (data not shown). Gender did not modify the relationship between perceived devaluation and STI testing.  2.4 Discussion This study presents an investigation into the experiences of perceived drug-related stigmatization in a group of street-involved youth and examines how these experiences influence their STI testing uptake. Most participants perceived a high level of stigmatizing attitudes towards PWUD. Overall, 87% of the participants reported high levels of stigma on the perceived devaluation scale. Such a high prevalence of perceived devaluation among street-involved youth could be attributed to their experiences of multiple layers of the stigma associated with being perceived as ‘troubled youth’ – reflecting ageism, stereotypes about young people who are street-involved, as well as normative views regarding risky sexual and drug use practices. While data on perceived drug-related stigma among youth is sparse, these findings are similar to a previous study on a sample of 1008 street-outreach adult PWID where 85% of the participants reported perceived devaluation. Feelings of perceived stigma in the current study were higher than those reported 18  amongst an adult drug using population (60%) recruited from residential and outpatient addiction treatment centres in the United States (84). These differences could in part be explained by differences between the scales used in the current study and the US-based study, or they could reflect the findings of other studies that have found that young people report more stigma than adult populations with regards to HIV/STI-related stigma (59). Higher perceptions of devaluation among the participants in the current study were significantly associated with lower STI testing uptake. This complements the findings of previous studies suggesting that externalized sources of stigma affect sexual health practices of youth and create barriers to their STI testing uptake (93-97).  Limited research on the role of perceived stigma on PWUD’s health outcomes could be due to perceptions that stigma deters drug use and therefore, has trivial negative effects on the mental and physical health of PWUD; however, recent empirical research proves this hypothesis wrong (79). However, Ahern and Stuber (2007) did not find any significant associations between perceived devaluation and the physical or mental health of PWUD. They suggest that in the context of drug use stigma, perceived devaluation of PWUD may be less important for health outcomes than their internalized feelings of stigma. They argue that perceived devaluation may be more prominent in stigmatizing attributes with a permanent or innate source of stress (e.g., racial or sexual minorities), in comparison with the transient perceptions of stigma among PWUD, which is not an unchangeable imposed identity at birth (79). Nonetheless, despite the narrow body of evidence on the association between perceived devaluation and health outcomes among PWUD, findings of this study are in line with a large body of literature in other marginalized populations (e.g., racial or sexual minorities; mental health patients) pointing to a strong relation between perceived devaluation and harmful health outcomes (98-100). Interestingly, having accessed drug 19  or alcohol treatment previously was significantly associated with higher STI testing uptake. It is possible that those who are already engaged with the health care system through addictions treatment services may experience lower levels of anticipated stigma when they need to access STI testing services. For young PWUD, interactions with addictions care providers could offer a trusted connection with health care providers, which may counteract the underlying effects of perceived devaluation. Hence, further research in understanding the effects of perceived devaluation on health outcomes among young PWUD would be beneficial.  Sex did not modify the effect of perceived devaluation on STI testing uptake; yet, it remained a significant confounder of the observed association. The odds of STI testing among young women was approximately three times higher than young men. Although seeking STI testing varies across different sub-population of youth, young men have been shown to represent a disproportionately low rate of testing compared to young women (93-97). Low rates STI testing rates among young men have been associated with individual- and structural-level factors inside and outside the healthcare service delivery systems. For example, studies have shown how gender relations and masculinities influenced by a set of social expectations influence men’s sexual health practices and experiences (89, 93-97). Also, these experiences have been linked to anxiety-inducing environments of STI testing clinics for young men where their sexual orientation is interrogated (93). Moreover, the sexual healthcare delivery system seems to be set to a ‘default system’ whereby women are positioned to take on the bulk of sexual and reproductive health responsibilities. Future interventions aimed at increasing STI testing uptake among marginalized youth could perhaps be more effective if they were to concomitantly take up a more gender-sensitive approach to addressing STI-related stigma reduction. The current study has some limitations that are common to studies on such hard-to-reach populations. While efforts were made 20  to recruit a representative sample of street-involved youth, given the non-random recruitment approach used, these findings may not be generalizable to all street-involved youth or PWUD in Vancouver; however, the demographic profile of this sample is similar to other studies on street-involved youth in British Columbia (101, 102).  Given the lack of substance abuse stigma scales among young PWUD, the measures used in this study were directly adopted from an earlier study on adult PWUD and adjusted for this population and could potentially suffer from issues with content validity. Future research could illuminate what items might be modified, added, or removed from the measure of perceived devaluation among street-involved young PWUD. Moreover, the instrument used to gather data in the ARYS study did not include multiple items  to measure the various facets or types of stigma. In future, it could be useful to include additional items to assess various types of stigma (e.g., anticipated stigma) in order to more fulsomely assess the impacts of multiple types of stigma on STI testing uptake among uptake young PWUD. Lastly, similar to other studies among this sub-population, these interpretations were prone to self-reported, recall, and social desirability biases. However, efforts were made to increase the accuracy of the data by limiting the analysis to recent variables (past six months).  2.4.1 Conclusions In summary, this study suggests that young PWUD experience high levels of perceived stigma, and that associated experiences of perceived devaluation may decrease STI testing uptake.  These findings have implications for health policy makers, healthcare providers, and researchers. Considering the adverse impact of perceived devaluation on STI testing practices of street-involved youth, it is important for healthcare staff to attend to the effect of perceived stigma (and the multiple facets through which stigma is generated) on their clients. Moreover, existing STI testing policies and procedures should be examined to assess their unintentional contribution to stigmatizing 21  behaviours towards young PWUD. Interventions targeting care providers to reduce stigmatizing attitudes or behaviours towards this subpopulation could be helpful in encouraging marginalized youth to seek sexual health care. Shifting the focus onto the system and providers may provide an important means by which to better meet the special needs of street-involved youth in non-stigmatizing ways by concentrating on intersecting forms of stigma (e.g., ageism, drug use, gender stereotypes) among marginalized youth. Future research could also aim to develop stigma measures to capture different experiences of stigma among them and assess how different layers of stigma affect young PWUD’s sexual health seeking practices.    22  Table 2.1: Baseline Sample Characteristics Stratified by STI Testing Uptake in the Previous Six Months among Street-involved Youth in Vancouver, Canada Characteristics Total n=300 (%) STI test=Yes n=88 (29.3%) STI test=No n=212 (70.7%) P-value Self-perceived devaluation     Low 19 (6.3) 8 (9.1) 11 (5.2) 0.185€ Moderate 20 (6.7) 3 (3.4) 17 (8.0)  High 261 (87.0) 77 (87.5) 184 (86.8)  Age (Years)     <19 15 (5.0) 4 (4.5) 11 (5.2) 0.816€ ≥19 285 (95.0) 84 (95.5) 201 (94.8)  Aboriginal ancestry     Yes 85 (28.3) 29 (33.0) 56 (26.4) 0.252 No 215 (71.7) 59 (67.0) 156 (73.6)  Sex     Female 109 (36.3) 50 (56.8) 59 (27.8) <0.001 Male 191 (63.7) 38 (43.2) 153 (72.2)  Education     ≥ high school 93 (31.0) 25 (28.4) 68 (32.1) 0.560 < high school 202 (67.3) 61 (69.3) 141 (66.5)  LGBTT     Yes 68 (22.7) 22 (25.0) 46 (21.7) 0.575 No 229 (76.3) 66 (75.0) 163 (76.9)  Stable relationship     Yes 91 (30.3) 31 (35.2) 60 (28.3) 0.245 No 208 (69.3) 57 (64.8) 151 (71.2)  Depression (at baseline)     Yes 121 (40.3) 39 (44.3) 82 (38.7) 0.300 No 151 (50.3) 40 (45.5) 111 (52.4)  Unprotected sex*     Yes 220 (73.3) 68 (77.3) 152 (71.7) 0.274 No 78 (26.0) 19 (21.6) 59 (27.8)  Involvement in sex work*     Yes 38 (12.7) 18 (20.5) 20 (9.4) 0.009 No 262 (87.3) 70 (79.5) 192 (90.6)  Sex with an HIV/STI-infected partner*     Yes 33 (11.0) 12 (13.6) 21 (9.9) 0.347 No 267 (89.0) 76 (86.4) 191 (90.1)  Multiple sex partners*     Yes 144 (48.0) 49 (55.7) 95 (44.8) 0.076 No 154 (51.3) 38 (43.2) 116 (54.7)  Injection drug use*     Yes 146 (48.7) 48 (54.5) 98 (46.2) 0.189 No 154 (51.3) 40 (45.5) 114 (53.8)  Non-Injection drugs binge use*     Yes 114 (38.0) 36 (40.9) 78 (36.8) 0.504 No 186 (62.0) 52 (59.1) 134 (63.2)  Binged on alcohol*     Yes 111 (37.0) 38 (43.2) 73 (34.4) 0.244 No 180 (60.0) 50 (56.8) 130 (61.3)  Accessed drug or alcohol treatment*     Yes 150 (50.0) 57 (64.8) 93 (43.9) <0.001 23  Characteristics Total n=300 (%) STI test=Yes n=88 (29.3%) STI test=No n=212 (70.7%) P-value No 150 (50.0) 31 (35.2) 119 (56.1)  Daily meth use*     Yes 74 (24.7) 22 (25.0) 52 (24.5) 0.931 No 226 (75.3) 66 (75.0) 160 (75.5)  Daily cocaine use*     Yes 3 (1.0) 0 (0.0) 3 (1.4) 0.558€ No 297 (99.0) 88 (100.0) 209 (98.6)  Daily heroin use*     Yes 75 (25.0) 27 (30.7) 48 (22.6) 0.143 No 225 (75.0) 61 (69.3) 164 (77.4)  Daily crack use*     Yes 15 (5.0) 6 (6.8) 9 (4.2) 0.352 No 285 (95.0) 82 (93.2) 203 (95.8)  Public injection drug use*     Yes 106 (35.3) 38 (43.2) 68 (32.1) 0.057 No 193 (64.3) 49 (55.7) 144 (67.9)  Homelessness*     Yes 141 (47.0) 40 (45.5) 101 (47.6) 0.793 No 158 (52.7) 47 (53.4) 111 (52.4)  Living in Downtown Eastside*     Yes 90 (30.0) 30 (34.1) 60 (28.3) 0.319 No 210 (70.0) 58 (65.9) 152 (71.7)  Warrants/area restrictions*     Yes 89 (29.7) 33 (37.5) 56 (26.4) 0.062 No 209 (69.7) 55 (62.5) 154 (72.6)  Incarceration*     Yes 40 (13.3) 10 (11.4) 30 (14.2) 0.540 No 259 (86.3) 77 (87.5) 182 (85.8)  Health services utilization*     Yes 248 (82.7) 81 (92.0) 167 (78.8) 0.006 No 52 (17.3) 7 (8.0) 45 (21.2)  Sexual/physical violence *     Yes 100 (33.3) 35 (39.8) 65 (30.7) 0.141€ No 198 (66.0) 53 (60.2) 145 (68.4)  Note: “€” P-value is obtained from Fisher’s exact test because of small cell count; “£” refers to continuous variable, P-value is generated from Wilcoxon rank-sum test; * Activities/behaviours in the previous 6 months; CES-D standard cut-off score of 22 or greater; LGBTT: Lesbian/Gay/Bisexual/Transvestite/Transsexual.           24  Table 2.2: Univariable and Multivariable GEE Analyses of Factors Associated with STI Testing Uptake among Street-involved Youth in Vancouver, Canada Variables Unadjusted Odds Ratio (95% CI) P-value Adjusted Odds Ratio (95% CI) P-value Self-perceived devaluation     Moderate vs. Low 0.23 (0.06 - 0.82) 0.024 0.28 (0.07 – 1.16) 0.079 High vs. Low 0.45 (0.19 - 1.10) 0.081 0.38 (0.15 – 0.98) 0.045 Age (≥19 vs. <19) 1.02 (0.35 - 3.02) 0.969   Aboriginal ancestry (Yes vs. No) 1.29 (0.79 - 2.08) 0.305   Sex (Female vs. Male) 3.04 (1.93 - 4.80) <0.001 3.61 (2.24 – 5.82) <0.001 Education (≥ high school vs. < high school) 0.84 (0.52 - 1.36) 0.482   LGBTT (Yes vs. No)δ 1.25 (0.75 - 2.10) 0.394   Stable relationship (Yes vs. No) 1.15 (0.76 - 1.74) 0.511   Depression (at baseline) 1.44 (0.90 - 2.29) 0.129   Unprotected sex (Yes vs. No)* 1.22 (0.77 - 1.95) 0.400   Involvement in sex work (Yes vs. No)* 2.65 (1.53 - 4.60) <0.001   Sex with an HIV/STI-infected partner (Yes vs. No)* 1.23 (0.69 - 2.19) 0.485   Multiple sex partners (Yes vs. No)* 1.68 (1.15 - 2.43) 0.007 1.68 (1.08 – 2.61) 0.021 Injection drug use (Yes vs. No)* 1.32 (0.86 - 2.04) 0.207   Non-Injection drugs binge use (Yes vs. No)* 1.21 (0.76 - 1.93) 0.412   Binged on alcohol (Yes vs. No)* 1.16 (0.76 - 1.79) 0.490   Accessed drug/alcohol treatment (Yes vs. No)* 2.35 (1.55 - 3.56) <0.001 2.53 (1.61 – 3.99) <0.001 Daily meth use (Yes vs. No)* 1.07 (0.67 - 1.73) 0.773   Daily cocaine use (Yes vs. No)* 2.18 (0.38 - 12.45) 0.380   Daily heroin use (Yes vs. No)* 1.38 (0.85 - 2.23) 0.187   Daily crack use (Yes vs. No)* 0.96 (0.35 - 2.62) 0.943   Public injection drug use (Yes vs. No)* 1.51 (0.97 - 2.33) 0.065   Homelessness (Yes vs. No)* 0.97 (0.63 - 1.51) 0.905   Living in DTESɓ (Yes vs. No)* 1.35 (0.84 - 2.15) 0.213   Warrants/area restrictions (Yes vs. No)* 1.16 (0.72 - 1.87) 0.544   Incarceration (Yes vs. No)* 1.06 (0.55 - 2.05) 0.852   Health services utilization (Yes vs. No)* 2.53 (1.31 - 4.86) 0.005   Sexual/physical violence (Yes vs. No)* 1.46 (0.94 - 2.26) 0.091 1.41 (0.86 – 2.30) 0.171 * Behaviours refer to activities in the last six months; δ LGBTT: Lesbian/Gay/Bisexual/Transvestite /Transsexual; ɓ DTES: Downtown Eastside    25  Chapter 3: Stigma Associated with STI Testing in an Online Testing Environment: Examining the Perspectives of Youth in Vancouver, Canada  3.1 Introduction        Sexually transmitted infections (STI) are a significant and increasing public health concern worldwide. The World Health Organization (WHO) estimates that approximately 357 million new cases of curable STI (e.g., syphilis; gonorrhea; chlamydia; trichomoniasis) occur worldwide every year (103). Within most global contexts, reported rates of most STI are higher among women than men; women are more likely to experience asymptomatic cases. For example, gonorrhoea and syphilis remain asymptomatic in 50-80% of women as compared with less than approximately 10% of men (104). Untreated STI in women can lead to serious health problems, including increased infertility rates, ectopic pregnancy, premature delivery, stillbirth, low birth weight offspring and neonatal infections (104, 105). Men who remain untreated may experience elevated risks of developing epididymorchitis, increased infertility rates, as well as penile or anal cancer (104, 105). Untreated STI (e.g., herpes and syphilis) can raise the risk of both acquisition and transmission of HIV by three-fold or more (103).        As such, there is a strong public health impetus to promote testing. However, within many settings, STI testing remains a highly stigmatizing experience – particularly for youth (63, 106). Previous research has demonstrated that young people experience enacted (i.e., stigma characterized by “actual” experiences of prejudice, stereotyping or discrimination from others), internalized (i.e., internalized, negative self-judgments that detrimentally affect one’s self-identity), anticipated  (i.e., expectations that an individual will experience prejudice, stereotyping 26  or discrimination from others), and perceived stigma (i.e., perception of the prevalence of stigmatizing attitudes in the community) during clinical encounters (63, 64, 95, 107). Age-based and gendered power dynamics also can be implicated in stigma experienced by young people during clinical examinations and pre/post-test counselling (89, 108). Furthermore, concerns about anonymity and confidentiality have been identified as barriers to STI testing among youth (63, 64, 109), as have inconvenient clinic locations, hours of operation and long wait times (110, 111).  Gender norms and stereotypes also influence how young men and women perceive and experience stigma associated with STI testing (89, 106). For instance, social norms that promote conservative forms of sexual morality (e.g., abstinence before marriage; limited number of sexual partners) might create fears of being labeled as “dirty” or “slutty” among young women who present at clinics for STI testing, especially for those who test positive for an STI (110, 112). In addition, in the context of seeking sexual health care, notions of emphasized femininity (e.g., viewing women as sexual health caretakers) in combination with hegemonic masculinity (e.g., associating men’s robustness with avoidance of seeking health care services; denial of disease; self-treatment) can shape youth’s experiences of STI testing practices (89, 110, 112, 113).        To reduce stigma associated with STI testing and enhance testing participation rates, particularly among “at risk” populations (e.g., young people), novel strategies (e.g., online testing services) are being explored in hopes that they will better resonate with young people and reduce barriers to testing (96, 112, 114). These efforts aim to provide less stigmatizing, “low threshold” STI testing services (112) and include STI testing services that are offered wholly or partially via the Internet (96, 114-117). However, there has been little empirical work to examine how online 27  testing serves to mitigate, ameliorate or exacerbate experiences of the stigma associated with STI testing among young people.          While online approaches offer the promise of reaching untested populations (118), the understanding of whether online services overcome, do not affect, or exacerbate stigma associated with STI testing remains limited. In particular, current knowledge on how stigma may function in an online milieu – particularly how stigma may function differently among young men and women – is limited. Understanding how gender and stigma are intertwined within online STI testing environments may help us to understand why young men and women have different experiences of the stigma associated with STI testing – which may enable the integration of a more robust, gendered approach to address stigma within online STI testing interventions. The purpose of the current study was to examine youth’s perceptions on how stigma associated with STI testing might be perceived to differ in an online milieu as compared with conventional, face-to-face clinical service provision. In doing so, this study seeks to identify the extent to which gender stereotypes feature within participants’ narratives regarding the internet-based testing as compared with “usual care.” 3.2 Methods 3.2.1 Study Setting        The study was conducted during 2012-13 in Vancouver, British Columbia (BC), Canada, where STI testing is offered in walk-in medical clinics, sexual health clinics, hospitals, and public health units. Some clinic-based testing sites provide services during weekends and evenings, although most only operate only 9am-5pm during weekdays. In the province of BC, reported rates of chlamydia and gonorrhea among youth have risen dramatically since the late 1990s (119). For 28  example in BC, the annual rate of genital Chlamydia more than doubled (118.9 per 100,000 to 288.4 per 100,000) from 1998 to 2014, with the highest rates being reported among young adults (20-29 years) followed by adolescents (15-19 years) (119). The annual rate of genital gonorrhea in BC has almost tripled from 1998 to 2014 (13.5 to 38.9 per 100,000), with males experiencing twice the rate of females (119). In 2014, the highest rates of gonorrhea among men were reported in 25 to 29-year-old males (180.8 per 100,000 population) and among women were in 20 to 24-year-old females (88.9 per 100,000 population)(119).          Based, in part, on evidence indicating that youth in Canada are familiar and receptive to the internet, with over 97% of youth ages 12-29 being regular online information seekers (120, 121), the BC Centre for Disease Control (BCCDC) recently launched Get Checked Online (GCO) – an online STI/HIV testing service currently available in Metro Vancouver (www.getcheckedonline.com) (122) and designed to complement current face-to-face, clinic-based testing services. Using GCO, clients complete an online risk assessment and print a lab test requisition forms to take to one of six laboratories (located in different neighbourhoods in Metro Vancouver), where they provide specimens for analysis (122). GCO was developed with the aim of promoting STI/HIV testing among young people (and other population subgroups with a higher prevalence of infection) (122). Moreover, the online program aims to offer a degree of anonymity and privacy for those seeking testing. Online sexual health services have been previously demonstrated to enhance information-seeking behaviour related to sensitive health-related topics (e.g., STI) (63, 112). 29  3.2.2 Sampling/Recruitment        A total of 71 participants (15-24 years old) were recruited through the use of online (e.g., postings to youth list-serves, advertisements on online forums such as Facebook) and offline recruitment strategies (e.g., posters and pamphlets in community venues, college campuses, and sexual health clinics). A purposive sampling strategy was used to deliberately recruit young men and women from a variety of socio-cultural backgrounds with various previous experiences with STI testing. Potential participants contacted youth sexual health team office by phone or e-mail and were screened for eligibility based on the following criteria: (i) ages 15-24; (ii) English speaking; (iii) residing in Metro Vancouver; (iv) self-identified as currently or previously sexually active; (v) and have gone or considered going for STI testing. Participants who met the eligibility requirements were invited for a 60-90-minute in-depth, individual interview, which took place in a private research office at the university. Youth received a CAD$25 honorarium for their participation in the interview. All procedures performed in studies involving human participants were in accordance with the ethical standards of The University of British Columbia Behavioural Research Ethics Board. Informed consent was obtained from all individual participants included in the study.  3.2.3 In-Depth, Individual Interviews        Before each in-depth interview started, the interviewer described the purpose of the study and obtained written informed consent. Participants were offered the opportunity to be interviewed by their preference of either a male or female interviewer. Participants also completed a 20-item socio-demographic questionnaire. Interviews started with participants’ discussion of their Internet use in general and their health information seeking behaviour. Next, participants were asked to 30  describe their perspectives and experiences with STI testing in clinic-based settings. Participants were then presented with a brief scenario describing the GCO testing service (Figure 1) and asked to share their perspectives on how experiences of STI testing in the online setting would compare to those within conventional, face-to-face clinical settings. They were also asked a series of questions to elicit their perspectives on whether and how representations of gender stereotypes around clinic-based STI testing might (not) be reproduced in an online testing environment. 3.2.4 Data Analysis        Interviews were audio-recorded and transcribed verbatim. Personal identifiers were removed from transcripts and pseudonyms were assigned. Transcripts were checked for accuracy and then uploaded to QSR NVivo 10 software for coding. An initial set of codes were generated and assigned to the raw data (123). As the analysis progressed, recurring, converging and new codes within the interview data were identified. The primary codes that emerged during the analysis included: (i): Stigma: This code refers to discourses that incorporate youth’s perceived experiences of stigma associated with testing in clinic-based versus online environment; (ii) Motivations/Demotivations to use online testing: This code captures discussions and references to youth’s reasons for seeking online testing (or not);  (iii) Confidentiality and privacy: This code includes discussions of confidentiality considerations that impacts youth’s uptake of online testing; (iv) Gender: This code captures discussions related to gender issues (e.g., gender roles; gender identity; relations among genders) and reference to masculinities/femininities associated with online testing. In addition, three overarching conceptual themes were identified: (i) Neutralizing external stigma (i.e., all forms of stigma which are not internalized); (ii) Persistence of internalized 31  stigma; (iii) Gender stereotypes and experiences of stigma. Quotations from the interview transcripts are used to illustrate specific features of the codes and themes.  3.3 Results 3.3.1 Study Participants        A total of 71 young people were interviewed: 42 female-identified and 29 male-identified youth. Participants were aged 15–24 years and came from a diverse set of socio-demographic backgrounds. To summarize, most participants self-identified as White/Caucasian (n=43, 60.5%), were born in Canada (n=52, 73.2%), and currently resided with their families (n=25, 35.2%). Most (n=51, 72%) of the participants self-identified as heterosexual and 66% (n=47) indicated they were involved a sexual relationship at the time of the study. Many participants (n=46, 65%) had previously accessed STI testing in clinic-based venues; all were naive to GCO (the program had not been launched at the time of data collection). Participants in the current study all learned of GCO’s existence for the first time when it was described during the interviews. See Table 3.1 for details regarding the participants’ socio-demographic characteristics.         The description of the findings begins with descriptions of the participants’ perceptions about how HIV/STI-related stigma may or may not be (re)produced in an online testing setting, followed by a section regarding gender stereotypes and online testing experiences. Details of participants’ pseudonyms, self-identified ethnicity, sexual orientation, and the number of times they reported having been tested for STI are provided in brackets after each quote. 32  3.3.2 Online STI Testing and Perceptions of Stigma Neutralizing External Stigma  Most study participants indicated that they perceived stigma to be associated with testing at clinics or online; but, they acknowledged that there could be important differences between online environments as compared to clinic-based settings. With reference to clinic-based settings, participants described how the process of sitting in a waiting room (and feeling surrounded by other people in clinic waiting room) could be a particularly anxiety-inducing experience. Participants indicated that they perceived that this type of anxiety could be alleviated in an online testing milieu. For instance, Nancy described how her experience of being in a waiting room in a sexual health clinic would have been different if she could have taken the test online: It’s not a pleasant atmosphere [being in the waiting room]. […] I’ve been sitting there and there will be like a girl crying and I’ll be like “Fuck. Is that going to be me? Poor thing. What’s she going through?” When you are in that space and there are other people waiting outside, you’re going to like - you’re waiting with all of these people, you go in, get some bad news and you have to walk past all those people again. If you’re crying, they’re all going to be wondering what’s wrong. And, they’re all going to automatically assume it’s the worst. But through this [online STI testing], there’s no wait and you are leaving outsiders […] out of your personal health, which I think is a good thing (Nancy, 21, Caucasian, Straight, Tested 10 times)         In addition to concerns about being judged by people in waiting rooms, participants also highlighted their concerns about feeling stigmatized or judged by health care providers. Again, most participants indicated that the fear of experiencing judgmental interactions with clinicians 33  could be largely ameliorated through online testing. As Adam noted, where face-to-face interactions or discussions are eliminated, the anxiety associated with the fear of being judged or stigmatized is also reduced or eliminated:  I think that online STI testing would just sort of take away the stuff like answering to an adult that you don’t know and who’s gonna ask you a bunch of embarrassing questions or uncomfortable questions. If you do it online, then you don’t really have to worry about doing that anymore. It sort of detaches that part of the interaction and I guess makes it a bit easier. (Adam, 18, Caucasian, Gay, Tested once)         Within participants’ discussions of online testing, most emphasized how the online setting could provide what they frequently characterized as “neutral” spaces where they could feel more comfortable about disclosing potentially stigmatized sexual activities (e.g., having sex without a condom; engaging in casual sex; having multiple concurrent partners). Some women in the current study explained that they would be less likely to underreport their sexual activities (e.g., number of sex partners) during an online risk assessment. Anita elaborated on how she perceived that stigma might influence her responses to questions used in a sexual history taking (a tool frequently used in a face-to-face, clinic-based testing environments): Some people don’t want to be honest in front of somebody because they don’t want to look like a slut. […] Even if it’s just a nurse trying to do her job. Online it’s more like, “I’m filling out this questionnaire. No one else is going to see this. I can be as honest as I want.” Say, I had slept with 20 people. In an office [clinic-based settings], I might lie and say, “Oh, I only slept with 10 people.” Right? Because, it’s a pride thing. People don’t want to 34  look like they’re overly sexually active. They don’t want to look like they’re sleeping around. (Anita, 24, Aboriginal, Transgender, Never tested)         Youth also commented that enhanced feelings of privacy and perceptions of confidentiality associated with Internet-based testing would mitigate experiences of stigma. When youth felt more secure that their testing experience would be kept private, they expressed less concern regarding experiences of judgment or reproach from peers, friends, or family members. Most participants acknowledged that the anonymity of online testing, as well as enhanced feelings of autonomy and control over the testing experience (e.g., doing it on their own time and in places where they felt safe), represented a significant advantage over the conventional settings.  As Chloe explained: I think you’d be considerably more likely to do something like that online rather than at a clinic because you don’t ever have to say anything out loud, you don’t have to tell anyone about it, you can erase your web browser history, you can do all these sorts of things and then, you can – you know, like, it’s like this, you can print off the requisition form and you can go to a lab and you can be going to a lab for anything. (Chloe, 23, Caucasian, Bisexual, Never tested)         Therefore, the prospect of submitting an online risk assessment alleviated many of the participants’ concerns of being “judged” and many cited the heightened anonymity and privacy associated with the Internet as potentially enhancing the likelihood that they would choose to seek STI testing. As Adam commented:    I think when you submit a form online, you think - I don’t know, you sort of assume that it’s going to be a computer. Like, especially like a radio button form. Like, you assume that 35  it’s going to be automatically wrung through some sort of algorithm to sort and send you stuff. It’s not going to be looked at by another person, and machines can’t judge you really. (Adam, 18, Caucasian, Gay, Tested once)        Within their descriptions, some youth also emphasized how, compared to clinic-based testing, fears of stigmatization could be moderated by enhanced feelings of control through the use of Internet-based testing. For example, by “taking control” of their own STI testing experience, participants suggested they would experience a higher degree of agency in the process, and would thus feel less vulnerable to the judgments of others. Anita explained how online testing might influence her experiences of seeking an STI test:  You can do it on your own, on your own time, stay in the safety of your bedroom. You can go, “I’m going to do this today.” Grab the papers, throw them in your backpack so no one else sees, go to this place, get it done and it’s done and over with. You don’t have to worry about sitting in a room. (Anita, 24, Aboriginal, Transgender, Never tested)        The fact that they could initiate testing on their own terms, including on their own time, and with their own computer or hand-held device represented a significant advantage over clinic-based testing environment. Persistence of Internalized Stigma         Despite youth’s overall conception that online testing would reduce their experiences with external stigma, some participants described how they might continue to internalize negative self-judgments concerning their sexual behaviours. For example, Cameron explained:  I think that for some cases if the reason why youth sort of don’t go in is because of external stigma, I think online could definitely help in that regard. But I would say that probably 36  it’s more likely that the reason is sort of internal shame or internalized notions and mentality in which case I don’t – in which case online testing wouldn’t be as effective. (Cameron, 23, Chinese, Straight, Tested twice)        As such, as the interviews progressed, some participants described how the online risk-assessment questionnaire could potentially elicit feelings of discomfort and shame – regardless of the control and privacy associated with the approach. For example, Kir described: I mean I guess any of those things could potentially evoke feelings of shame, right? Cause I guess if you’re not satisfied with some of the choices you’ve made, having to answer those questions honestly can be hard. I know I’ve struggled with that before. You know, when people ask like how many partners you have had. It’s like... So I guess potentially any of those questions, could evoke feelings of shame. (Kir, 21, Caucasian, Straight, Never tested)         Some participants also talked about how their internalized feelings of being “at fault” would enforce previously internalized experiences of shame regarding STI testing regardless of whether the testing was conducted in a clinic or online: There’s still a possibility of shame. You still have to deal with the after fact of being tested. Some people might feel shame, if, again, it comes up positive. “Oh, it’s my fault I got the disease. It’s my fault. I’m bad.” Some people might start blaming themselves for it and making themselves feel worse whether it be online or going to get tested regularly, it’s just -- some people have that mentality where, no matter what the outcome, they still will put themselves down for it. (Anita, 24, Aboriginal, Transgender, Never tested) 37 Gender Stereotypes         Most participants suggested that young women would be more inclined and interested in seeking online STI testing, often citing how pre-existing stigma around STI testing is a phenomenon that is somewhat heightened for women. Many participants’ descriptions were framed in ways that aligned with or re-affirmed many gendered stereotypes about women. For example, stereotypes were frequently used to describe women as being more likely to seek online STI testing (to avoid embarrassment) and men as less concerned about feelings of embarrassment when seeking STI testing in clinic-based settings. Other narratives also reflected stereotypes that position young women as being more inclined to online testing because they were more “naturally” predisposed to taking care of their own health and the health of others, as compared to young men. Some participants also talked about how they thought young women were more anxious about their health and “paranoid” about sexual risk by nature and therefore more likely to seek online STI testing.  For example, Melissa outlined:   Yeah I mean I think females are probably the ones that are more likely to go looking… like… to go check online… I mean I have no idea I’m not a guy but I feel like women are more paranoid about their health in general so they’re like ok let’s look this stuff up. You know… if you get pregnant let’s do something about it. Guys are like: “Whatever… get it dealt with…” that kind of thing. I feel in general probably such testing settings [online]…majority will be used by females. (Melissa, 21, Caucasian, Straight, Never tested)  Participants also seemed to agree with the general notion that men tend to avoid accessing or discussing STI testing services, regardless of whether they were offered in clinics or online. However, the responses around questions about men’s uptake of online testing were mixed, with 38  some participants indicating that either online STI testing or clinic-based testing would be perceived by most men to be a behaviour that would misalign with a set of dominant ideals about masculinity (e.g., stoicism and avoidance of help-seeking).  Other participants explained how accessing STI testing online could be a potential solution to promote men’s engagement with STI testing. For example, some described how they could retain their alignment with normative masculinity by seeking testing in an anonymous and private space; as Jimmy described: You can just go on the Internet and no one is really going to know. Even if you’re a manly person on the outside, deep down inside you’re going to look up some personal stuff and everyone is personal whether or not they show it on their everyday life. Maybe it would make it easier for them [men] to actually be private about it while still being manly on the outside (Jimmy, 21, Caucasian, Straight, Tested once).          These narratives distil how dominant expectations regarding masculinity and masculine behaviour represent significant barriers to men’s engagement with conventional testing services. As such, some participants described how men might represent the most significant beneficiary of online STI testing services and also be more likely to seek these anonymous and private services. For example, Natasha stated:   I definitely think they (men) would be more likely to access a website than like ask a peer or ask a nurse. Just cause it’s something you can do kind of privately and not tell anyone, and it’s like that. I guess if you don’t want to be like seen in your weakness, I guess that would be why you wouldn’t go to the doctor so if you want to do it discreetly and show 39  anyone that you’re slightly not masculine you might go online I guess. (Natasha, 23, Caucasian, Straight, Tested 3 times) 3.4 Discussion  None of the participants in the current study suggested that online testing might reinforce or exacerbate existing STI-related stigma; but, the results also indicate that gender stereotypes (and their links with STI-related stigma) could affect youth’s experiences with online testing. The findings of this study are consistent with the growing body of literature suggesting that utilization of online STI testing services may be acceptable to youth (96, 112). In the current study, participants commented that several aspects of Internet-based testing could potentially alleviate perceptions and fears of external stigma related to the STI testing experience. These included: accessibility and convenience of bypassing the clinic visits, avoidance of the anxiety inducing and judgmental environment of the waiting areas and clinical appointments, the potential online risk assessment as an alternative to the face-to-face encounter with healthcare providers, and enhanced privacy and anonymity. While direct interactions with healthcare providers can be arguably beneficial due to contextualization of body language, and dialogue flow (106, 112), participants in the current study described several potential benefits in seeking online STI testing and were receptive to and interested in such online interventions.         Conversely, whereas the perceived effects of STI testing-related external stigma appeared to be at least partially ameliorated through online testing, participants in the current study explained that internalized stigma (e.g., feelings of guilt or shame) associated with STI testing might not be significantly reduced in an online testing experience. This finding highlights the complexities around addressing internalized feelings of shame and stigma regarding testing for STI and is 40  consistent with other research that indicates that shame and stigma remain important barriers to young people using such services (95, 96). Campaigns to de-stigmatize STI and to break gender stereotypes could be viable strategies in normalizing and promoting STI test seeking practices among youth in either online or clinic-based settings.         Youth’s descriptions of stereotypes of gender around online and clinic-based STI testing align with previous studies indicating the important role of gender norms on youth’s sexual health information seeking practices (89, 95, 106, 112, 124, 125). In the current study, women were perceived to be more likely to seek online STI testing (89, 112). There is some evidence that online information sites position women as the principal reference for STI care practices (89, 112); this practice, alongside the ‘feminized’ spaces of many sexual and reproductive health clinics, may create barriers for young men’s sexual health information-seeking and care-seeking practices (63, 110). However, the evidence is mixed on the question of how to help young men feel more comfortable accessing STI testing services – online or in clinical settings. Highlighting the increased privacy and anonymity of online testing, participants in the current described online STI testing as a potential remedy for the existing gap in young men’s STI testing services (112).          There are several limitations to the current study. At the time of data collection, the online service (GCO) had not yet been made available for use. As a result, participants in the current study were asked to reflect on a detailed description of GCO’s online testing process and were invited to compare those perceptions with recollections of their own experiences with clinic-based sexual health services. Future research in this area would benefit from eliciting responses from youth who had actually had the opportunity to use the online testing service. In addition, the study was conducted with urban and suburban youth, and findings might differ if the study involved a 41  sample of young people living in rural settings, for whom it seems reasonable to hypothesize that the role of place in clinic-based testing-related stigma could be even more pronounced (63, 110). It also is worth noting that the current study relied on face-to-face interviews to gather data about the potential for an online STI/HIV testing service to alieviate stigma associated with face-to-face clinical service provision. Future research on HIV/STI related stigma and its links with face-to-face interactions could use alternative data collection methods (e.g., telephone or online interviews) to gather data from young people, particularly those youth who might feel most inhibited by face-to-face discussions about sensitive topics, such as STI/HIV testing or stigma. 3.4.1 Conclusions Having identified stigma as a significant barrier to STI testing among marginalized youth (see Chapter Two), the findings described here in Chapter Three describe youth’s experiences of stigma, including gender stereotypes associated with HIV/STI testing. The findings reported in the current chapter indicate that while online services might allow young users to bypass some aspects of stigmatization (e.g., externalized stigma), the potential for internalized feelings of shame to affect the online testing experience remains. Paying attention to this finding is important, as online STI testing is gaining popularity and has shown promising results in multiple settings around the globe. As the findings from the current study indicate, services like GCO could be optimized to better address the gendered stigma experiences of youth seeking testing. Having observed varying perceptions of HIV/STI-related stigma among young men and women – including perceptions about (re)production of gendered stigma in online testing – it is imperative to note that no single intervention (e.g., online testing) can entirely ameliorate the effects of HIV/STI-related stigma on young people, including those young people who are living with HIV (young PLHIV). To better 42  understand what how gender stereotypes and gender-based stigma pertaining to testing has been addressed in other relevant studies, Chapter Four examines how sex or gender has been accounted for within a subset of the peer-reviewed literature that purports to address HIV-related stigma amongst young PLHIV.                     43  Figure 3.1: Illustration Describing the GCO Testing Service as Presented to Participants 44  Table 3.1: Socio-demographic Characteristics of the Youth in a Qualitative Assessment of STI-related Stigma, Vancouver, Canada Characteristics Male (n=29) Female (n=42) Total (n=71) n (%) n (%) n (%) Age Group    15-17 years 8 (27.6) 9 (21.4) 17 (23.9) 18-24 years 21 (72.4) 33 (78.6) 54 (76.1) Ethnicity    Aboriginal 3 (10.3) 5 (11.9) 8 (11.3) Black 1 (3.4) 0 (0) 1 (1.4) Asian 8 (27.6) 10 (23.8) 18 (25.4) Latin American 1 (3.4) 0 (0) 1 (1.4) White/Caucasian 16 (55.2) 27 (64.2) 43 (60.5) Born in/Immigrated to Canada    Born 19 (65.5) 33 (78.6) 52 (73.2) Immigrated 10 (34.5) 9 (21.4) 19 (26.8) Number of years in Vancouver    <5 years 12 (41.4) 13 (31) 25 (35.2) ≥5 years 17 (58.6) 29 (69) 46 (64.8) Number of times tested    Never 9 (31.0) 16 (38.1) 25 (35.2) 1 9 (31.0) 2 (4.8) 11 (15.5) 2-3 8 (27.6) 9 (21.4) 17 (23.9) ≥4 3 (10.3) 13 (30.9) 16 (22.5) Do not know/remember 0 (0) 2 (4.8) 2 (2.8) Sexual relationship status    Currently involved 18 (62.1) 29 (69) 47 (66.2) Not currently involved 11 (37.9) 13 (31) 24 (33.8) Sexual orientation    Heterosexual/Straight 24 (82.7) 27 (64.3) 51 (71.9) Gay/Lesbian 4 (13.8) 2 (4.7) 6 (8.4) Bisexual 1 (3.5) 11 (26.2) 12 (16.9) Two-spirit 0 (0) 1 (2.4) 1 (1.4) Transgender 0 (0) 1 (2.4) 1 (1.4) Living arrangements    Living with parents/family 9 (31) 16 (38.1) 25 (35.2) Living with friends 6 (20.7) 13 (31) 19 (26.8) Living with a partner/spouse 2 (6.9) 3 (7.1) 5 (7) Living alone 6 (20.7) 3 (7.1) 9 (12.7) Other (e.g., foster care, shelter) 6 (20.7) 7 (16.7) 13 (18.3) 45  Chapter 4: An Analysis of Measures Used to Assess HIV-related Stigma among Young People Living with HIV: Missing Accounts of Sex and Gender  4.1 Introduction People living with HIV (PLHIV) experience internalized stigma (i.e., self-endorsing of negative beliefs and emotions attributed to HIV), enacted stigma (i.e., actual experiences of prejudice, stereotyping or discrimination from others), perceived stigma (i.e., Perception of the prevalence of stigmatizing attitudes in the community) and anticipated stigma (i.e., expectations that an individual will experience prejudice, stereotyping or discrimination from others)(11, 126). HIV-related stigma has been associated with adverse physical and mental health outcomes, including poor treatment adherence, social rejection, and exclusionary and physical distancing practices (11, 23, 24, 126, 127). HIV-related stigma may be compounded by other forms of social marginalization (11, 45). Many PLHIV belong to marginalized subgroups who already experience other forms of stigma associated with ethnicity, age, gender, sexual identity, and behaviours (e.g., drug use)(42, 45, 126).  Youth and adolescents living with HIV (YLHIV) may experience higher levels of perceived or enacted stigma than adults living with HIV due to ageism and being perceived as having higher risk substance use and sexual practices (18, 45, 128). For young people, exposure to HIV-related stigma occurs at a critical period in development, with often dire implications (e.g., being rejected or maltreated by family, the broader community, and service providers)(65, 66). Despite youth accounting for approximately 40% of the new infections globally (66), most studies have focused on HIV-uninfected youth’s attitudes towards HIV and PLHIV, to the exclusion of 46  other important aspects pertaining to YLHIV’s experiences with  HIV-related stigma (15, 67), including the ways in which sex- or gender-based differences might affect experiences of HIV-related stigma. For example, a recent study conducted in Uganda indicates that women living with HIV experience more discrimination from family members than do men living with HIV, while men living with HIV are more likely to experience stigma in relation to the broader community (53). In Swaziland, men living with HIV were more likely to report experiencing internalized stigma, while experiences of enacted stigma were more prevalent among women (54).  In light of evidence that research often fails to fulsomely account for sex and gender, limiting the equal applicability of the findings to both men and women (129), it may be useful at this juncture to conduct an assessment of the ways in which features of research design and measurement issues contribute to the current understandings of sex- or gender-based differences regarding HIV-related stigma (e.g., are these differences real or artefacts of measurement error or other forms of bias?). Thus, the aim of the current analysis is to review empirical studies that measure HIV-related stigma among YLHIV (women and men ages 10-24 years) and describe how sex or gender differences pertaining to stigma are accounted for in those studies (e.g., study design; concept operationalization; measurement). In so doing, this study hopes to inform future research approaches and practice, and improve the understanding of how young men and women may report different (or similar) experiences of HIV-related stigma.   4.2 Methods 4.2.1 Search Strategy A set of keyword search terms (1997-present) including HIV, stereotyping, shame, social isolation, stigma, social distance, prejudice, fear, discrimination, disclosure, youth, young, adolescent, teen, teenager, and attitude was used to search MEDLINE, EMBASE, and PsycINFO 47  using the OvidSP platform. Hand searches of the bibliographies of relevant published works and previous reviews were also performed (citation snowballing). Additionally, conference abstracts (2013-2015), including AIDS and International AIDS Society were searched and authors were contacted where necessary to obtain unpublished information.  4.2.2 Inclusion and Exclusion Criteria Studies measuring any facet of HIV-related stigma as their main explanatory or outcome variable and that enrolled young people (10-24 years old) who were living with HIV were included in the analysis. Studies that included a mix of HIV-positive and -negative participants were included if they reported on HIV-related stigma among YLHIV. Studies reporting stigma as a covariate in their regression models without a focus on stigma as the primary explanatory or outcome variable were excluded. The analysis was also limited to quantitative, peer-reviewed, original research studies published in English from 1997 - 2015 to reflect the period following the first published measure of HIV-stigma used with PLHIV (130).  4.2.3 Data Analysis  Items measuring HIV-related stigma among YLHIV were reviewed and coded based on a coding scheme informed by a modified version of the HIV stigma framework (11). This framework, the first of its kind, provides a comprehensive conceptual model that explains how HIV-related stigma can provoke individual level stigma mechanisms which result in important mental and physical health outcomes for those who are HIV-positive. This framework attempts to untangle different individual processes that HIV-positive populations encounter regarding the stigmatized nature of HIV. Measures were coded for items that assessed: enacted stigma, internalized stigma, perceived, and anticipated stigma. Items were coded as enacted stigma if they measured perceived experiences of prejudice or discrimination  (e.g., experiences including 48  discriminatory behaviours at healthcare settings; verbal abuse; social rejection; personalized stigma); as assessing internalized stigma if they measured the application of negative beliefs associated with HIV to the self (e.g., experiences of shame; guilt; worthlessness; negative self-image); as anticipated stigma if they measured the expectation of experiencing future prejudice and discrimination (e.g., experiences of anticipation of dislike; anticipation of limited job opportunities; disclosure concerns); and as perceived stigma if they measured perceptions of the prevalence of stigmatizing attitudes in the community (e.g., public attitudes towards PLHIV) (11).   Next, each study was evaluated on whether or how sex or gender was taken into account during the analysis and within the presentation of the results based on these criteria: (i) Using sex/gender-specific questions in a way that some questions/sub-sections are asked of young men/women only; (ii) Recruiting equal number of young men and women in the study sample to integrate the effect of sex/gender differences or specifying a plan for analyzing the data by sex and/or gender; (iii) Stratifying by sex/gender, or treating sex/gender as a covariate, or controlling for sex/gender; (iv) Acknowledging the importance of sex/gender considerations to be taken into account during the analysis (129). 4.3 Results 4.3.1 Characteristics of Included Studies Of the 1876 abstracts initially identified, 174 were included for full-text screening, and 22 papers fulfilled all inclusion criteria and were selected for data extraction (Figure 1). Most studies were conducted in the United States (15 studies), with others having been conducted in Thailand (3 studies), Sweden (1 study), Zimbabwe (1 study), South Africa (1 study), and Puerto Rico (1 study).  Five studies (43, 128, 131-133) examined HIV-related stigma as an outcome. Most examined the association of exposure to HIV-related stigma with one or several physical or mental 49  health outcomes. Several studies associated experiences of HIV-related stigma with lower ART adherence (134-136) and poorer mental health outcomes (135, 137-144) (Table 2.1).  Most studies used or modified the HIV stigma scale developed by Berger et al. in 2001 (145). Others reported using a self-designed scale based on literature review of peer-reviewed publications (140), the Sowell’s HIV stigma scale (43, 146) Swendeman’s HIV stigma scale (146), Social impact scale (139), HIV stigma scale for children (131), Perceived stigma scale (133), and HIV-Positive Identity Questionnaire (136). Four studies limited their focus to two subscales (anticipated and internalized stigma) (133, 135, 141, 147); two others measured perceived and enacted stigma (43, 148) and two others measured only enacted stigma (138, 149). Two studies measured only perceived stigma (146, 150), and one assessed only internalized stigma (136).  Four studies recruited only male YLHIV (136, 142, 146, 151) and five studies recruited only female YLHIV (133, 135, 141, 147, 150). Twelve studies (131-135, 138-141, 147, 148, 150) had not specified their participants’ sexual orientation. Of the 14 studies that measured subscales of the stigma associated with disclosure of HIV status (128, 131, 132, 134, 135, 137, 139-144, 147, 151), eight did not report any data on participants’ sexual orientation (131, 132, 134, 135, 139-141, 147). 4.3.2 Sex/Gender Analysis None of the studies included gender-specific questions. Eleven studies referred to sex- or gender-based differences, but none of the nine studies that included either only male or only female YLHIV discussed sex or gender considerations. Only one paper (143) used the terms “men”, “women” or “transgender” to describe their sample; there are four other studies that reported including transgender people in their sample and they categorized the remaining proportion of their sample as “male” or “female” (137, 140, 142, 149).  One study (128) stratified by sex (i.e., 50  male; female) and six studies treated sex as a covariate in their analyses (43, 138, 143, 144, 148, 149). Moreover, of the 14 studies that included both male and female YLHIV, six did not account for sex in their analyses (132, 134, 137, 139, 140, 142).  Of those studies that reported on sex/gender differences in their findings, most found that being female was associated with higher levels of perceived social rejection, shame, overall perceived stigma (43), as well as higher guilt-proneness, avoidant coping, depressive and internalizing symptoms (138). In one study of Thai YLHIV, Thai female YLHIV were more likely to disclose their HIV status to their immediate families and sexual partners and less likely to disclose to friends (151). In the stratified analysis presented by Harper et al. (2014), females were less likely to benefit from their stigma-reduction intervention than males (128). Other research conducted among YLHIV has not found gender to be independently predictive of HIV treatment adherence (148) or depression (144) amoungst YLHIV, nor has gender been identified as a significant confounder of the association of social support and HIV disclosure (149).  4.4 Discussion In order to review HIV-related stigma studies among YLHIV, the current study adapted Earnshaw & Chaudoir’s (2009) HIV stigma framework (11) as well as Johnson et al.’s (2014) approach to assessing sex- and gender-informed research. Overall, it was observed that there is little focus on young people in HIV-related stigma research, despite being a key HIV-affected population globally. It was also striking that most studies included in the review had not accounted for sex- or gender-based differences in relation to HIV-related stigma among YLHIV. Overlooking sex- and gender-based differences is concerning given the large body of evidence on how women living with HIV experience more social rejection, discrimination, shame, psychological distress, and perceived HIV stigma than men (43, 126-128, 138, 152). None of the 51  studies that included only a single sex (i.e., only male or only female participants) discussed sex or gender as being relevant to consider in their analyses. This coincides with previous trends within the published literature where researchers fail to perceive the relevancy of accounting for sex or gender influences in studies that include only one sex (e.g., only men) (129). More than half of the studies (n=14) in the current review included both males and females; yet, few reported sex-specific analyses or used sex-disaggregated data reporting. Furthermore, no study included in the current review used gender-specific stigma questions, and only one study stratified their findings by sex (128). Gender-specific stigma measures are available (153) and should be considered in future stigma studies.   A failure to more fulsomely account for sex and gender in HIV-related stigma studies leaves open the possibility of missing (or misunderstanding) potentially relevant sex- or gender- considerations related to experiences of stigma. Missing out on data that illustrates sex- or gender-based patterns (of differences or similarities) limits opportunities for understanding of underlying causes and mechanisms that could be addressed in stigma reduction interventions.  4.4.1 Strengths and Limitations The study methods required a close reading of the text and therefore only those studies that were available in full-text were included. As a result, some relevant studies may have been excluded from this review. Moreover, while efforts were made to include databases across different domains of medical and social sciences, the potentially relevant papers in other domains (e.g., policy or legal analyses; technical reports grey literature) may have been missed.   52  4.4.2 Conclusions  Combating HIV-related stigma is a priority, and young people remain at the center of the epidemic in many contexts. In addition to the current study, several others also have suggested that factors such as sex and gender (as well as other factors, including sexual orientation and ethnicity) should be considered in future research on HIV-related stigma among YLHIV (45, 53-55, 152). Paying attention to sex and gender is important to developing comprehensive understandings of HIV-related stigma experiences and to developing appropriate interventions to reduce HIV-related stigma. These findings highlight a gap in the current body of evidence and point to the need for future studies to use psychometrically valid scales to measure HIV-related stigma in sex- and gender-informed ways.   53  Figure 4.1: Study Inclusion Flowchart for Papers Measuring HIV-related Stigma among Youth Living with HIV       54  Table 4.1: Characteristics of studies measuring HIV-related stigma among youth living with HIV (YLHIV)  Author (Year)  Sample Age* Sexual orientation (%) Ethnicity (%) Stigma mechanism measured Outcomes measured Approach to accounting for gender in the presentation of findings Qu.α No.ɓ Cov.ɕ Ack.ɗ Swendeman et al. (2006) 116 Male 31 Female 23 (16-29)Ɨ Gay/Bisexual (74%) Hispanic (44%) African-American (24.5%) Caucasian (24.5%) Other (7%) Enacted stigma (ES) Perceived stigma (PS) HIV-related stigma No No Yes (Covariate) Yes Wright et al. (2007) 25 Male  22 Female 1 Transgender 16-25¥ Gay/Bisexual (64%) African-American (88%) Disclosure concerns (AS) Public attitudes (PS) Personalized stigma (ES) Negative self-image (IS) Psychosocial outcomes; Substance use No Yes No Yes Sayles et al. (2008) 20 Male 19 Female 1 Transgender 18-35¥ NR NR Disclosure concerns (AS) Social relationships (AS) Self-acceptance (IS) Public attitudes (PS) Mental health; Physical health   No Yes No No Dowshen et al. (2009) 36 Male 6 Transgender 16-24¥ Gay (85.7%) Black (45.2%) White (26.2%) Latino (23.8%) Other (4.8%) Disclosure concerns (AS) Public attitudes (PS) Personalized stigma (ES) Negative self-image (IS) Psychosocial outcomes No No No No Clum et al. (2009) 147 Female 20.6 (2.2) NR African-American (70.7%) Hispanic/Latino (22.5%) Other (7.8%) Disclosure concerns (AS) Negative self-image (IS) Engagement in risky behaviours; Depression; Perceived social support No No No Yes Dietz et al. (2010) 178 Female 20.6 (2.1) NR African-American (92.2%)  Disclosure concerns (AS) Negative self-image (IS) Appointment keeping No No No No Radcliffe et al. (2010) 40 Male 20.4 (2) Gay (75%) Bisexual (25%) African-American (100%) Perceived stigma (PS)  Sexual risk behaviour; Disease progression No No No No Rongkavilit et al. (2010) 26 Men 41 Women 3 Transgender 22.8 (2.1) Straight (70%) Gay (17.2%) Bisexual (12.8%) Asian (100%) Disclosure concerns (AS) Public attitudes (PS) Personalized stigma (ES) Negative self-image (IS) Quality of life; psychosocial outcomes; substance use No No Yes (Covariate) Yes Santamaria et al. (2011) 98 Male 98 Female 12.7 (2.18) NR African-American (57%) Latino (42%) Disclosure concerns (AS) Social rejection (IS) Internalized shame (IS) Disclosure status No Yes No No Andrinopoulos et al. (2011) 179 Female 21 (2.1) NR African-American (72.6%) Hispanic (21.1%) Other (6.3%) Perceived stigma (PS) Health-related quality of life No No No No 55  Author (Year)  Sample Age* Sexual orientation (%) Ethnicity (%) Stigma mechanism measured Outcomes measured Approach to accounting for gender in the presentation of findings Qu.α No.ɓ Cov.ɕ Ack.ɗ Martinez et al. (2012) 60 Female 20.6 (2) NR African-American (73%) Latina/Hispanic (20.8%) White (1.7%) Asian (0.6%) Other (2.8%) Disclosure concerns (AS) Negative self-image (IS) ART adherence; Psychosocial outcomes No No No No Tanney et al. (2012) 98 Male 88 Female 20.5 (2.3) Lesbian/Gay/Bisexual/Transgender (43.5%) African-American (83.3%) Disclosure concerns (AS) Public attitudes (PS) Personalized stigma (ES) Negative self-image (IS) Depression No Yes Yes (Covariate) Yes Wiklander et al. (2013) 31 Male 27 Female 13.9 (2.5) NR NR Disclosure concerns (AS) Public attitudes (PS) Negative self-image (IS) HIV-related stigma No Yes No Yes Mavhu et al. (2013) 94 Male 135 Female 14 (6-18) Ɨ NR African (100%) Perceived stigma (PS) Enacted stigma (ES) ART Adherence No No Yes (Covariate) Yes Visser et al. (2013) 609 Female 26.6 (5.5) NR African (100%) Internalized stigma (IS) Attributed stigma (AS) HIV-related stigma No No No Yes Washington et al. (2014) 39 Male 47 Female 13 (10-18.9)Ɨ NR Thai (96.5%) Disclosure concerns (AS) Public attitudes (PS) Personalized stigma (ES) Negative self-image (IS) HIV-related stigma No Yes No No Fongkaew et al. (2014) 17 Male  13 Female 14-21¥ NR Asian (100%) Disclosure concerns (AS) Public attitudes (PS) Personalized stigma (ES) Negative self-image (IS) ART adherence No Yes No No Harper et al. (2014) 28 Male 22 Female 19.2 (2.25) Straight (44%) Gay/Lesbian (38%) Bisexual (18%) African-American (78%) Asian (2%) White (2%) Mixed (8%) Other (10%) Disclosure concerns (AS) Public attitudes (PS) Personalized stigma (ES) Negative self-image (IS) HIV-related stigma No Yes Yes (Stratified) Yes Bennett et al. (2015) 49 Male 39 Female 18.3 (3) NR African-American (64%) Hispanic (17%) Caucasian (10%) Other (11%) Personalized stigma (ES)  Psychosocial outcomes No Yes Yes (Covariate) Yes 56  Author (Year)  Sample Age* Sexual orientation (%) Ethnicity (%) Stigma mechanism measured Outcomes measured Approach to accounting for gender in the presentation of findings Qu.α No.ɓ Cov.ɕ Ack.ɗ Lee et al. (2015) 202 Male 185 Female 15 Transgender 20.6 (2.4) Straight (42.9%) Gay/Lesbian/Bisexual (51.1%) Not specified (6%) African-American (56%) Hispanic/Latino (30.1%) White (5.7%) Other (8.2%) Social rejection and isolation (ES) HIV disclosure; Social support No Yes Yes (Covariate) Yes Hussen et al. (2015) 132 Male 20.9 (1.9) Gay/bisexual (100%) Black (100%) Negative self-image (IS) Identity Salience (IS) Engagement in care No No No No Rongkavilit et al. (2015) 74 Male 22.5 (2.1) Gay (78.4%) Bisexual (21.6%) Thai (100%) Disclosure concerns (AS) Public attitudes (PS) Personalized stigma (ES) Negative self-image (IS) Motivational Interviewing No No No No * Age data are Mean (SD) unless specified (¥ Range; Ɨ Median (Range)); NR: Not Reported; PS: Perceived Stigma; YLHIV: Youth and adolescents living with HIV; AS: Anticipated Stigma; ES: Enacted Stigma; IS: Internalized Stigma; α: Using sex/gender-specific questions; ɓ: Equal number of young men and women; ɕ: Treating sex as a covariate, stratifying by sex or controlling for sex; ɗ: Acknowledging the sex/gender considerations  57  Chapter 5: Summary of Findings, Implications for Policy and Research  The purpose of this thesis was to examine the experiences of HIV/STI-related stigma among young people and to assess the underlying forces of gender differences in HIV/STI-related stigma among youth. In the final chapter, I review the main findings of Chapters Two through Four and expand upon the implications for policy and sexual health services provision. I also propose topics for future research in this area.  5.1 Summary of Findings The findings described in Chapter Two focused on self-perceived devaluation and STI testing practices among a cohort of street-involved youth in a Canadian setting. The analysis examined whether perceived devaluation (a facet of perceived stigma) affected STI testing uptake among street-involved youth. This sexually active marginalized population reported high levels of perceived devaluation. High levels of perceived devaluation were found to be independently associated with decreased STI testing uptake amongst the study participants. These findings complement the findings of previous studies suggesting that externalized sources of stigma affect sexual health practices of youth and create barriers to their STI testing uptake (93-97). Based on the combined effects of STI-related stigma and gender in inhibiting engagement in STI testing and treatment uptake (89, 93, 95-97, 106), modifying effects of gender on this association were also examined. While gender did not independently interact with the observed association, it remained a significant confounder in bivariable and multivariable analyses.  The findings described in Chapter Three pertain to the stigma associated with STI testing in an online testing environment. The analysis described in Chapter Three examined the perspectives of youth regarding the potential for the stigma associated with STI testing to be 58  (re)produced in an online testing environment. Using data gathered through in-depth interviews with 71 young people (ages 15 to 24), the chapter’s findings aligned with a growing body of evidence suggesting that online STI testing services may potentially mitigate commonly reported barriers, including stigma (96, 112). Some anxiety-inducing experiences such as the process of waiting and being surrounded by other people in clinical waiting rooms, as well as judgemental interactions with healthcare providers, were thought to be largely ameliorable through online testing. Additionally, participants indicated that they perceived online testing to provide enhanced privacy and confidentiality, and increased feelings of control. Nonetheless, many participants’ descriptions were framed in ways that aligned with or re-affirmed many gendered stereotypes about men and women (89, 95, 106, 112) and indicated how gender stereotypes and youth’s use of online STI testing are interconnected. Additionally, online testing was not perceived as effectively mitigating tendencies to internalize negative self-judgments about sexual behaviours, highlighting the complexities around addressing internalized feelings of shame and stigma around testing for STI (95, 96)(94).    Chapter Four provided a review and analysis of measures used to assess HIV-related stigma among young people living with HIV. The results demonstrate that YLHIV remains understudied and underrepresented in HIV-stigma literature. Moreover, most studies on HIV-related stigma among YLHIV do not address the sex/gender differences in their analyses or interpretations. Out of 22 studies that fulfilled the inclusion criteria, four studies recruited only male YLHIV and five studies recruited only female YLHIV. None of the studies included gender-specific questions, only one study stratified by sex, seven studies treated sex as a covariate in their analyses, and out of 14 studies with a mixed sample of male and female YLHIV, six did not account for sex in their analyses in any ways; leaving open the likelihood of missing or misinterpreting potential relevant 59  sex- or gender- considerations related to experiences of stigma. This could limit opportunities to fully understand the underlying mechanisms that should be addressed in stigma reduction interventions.    5.2 Implications for Research and Policy  The current study relied on secondary analysis (and used both qualitative and quantitative techniques). The secondary analyses conducted in the current study were restricted in terms of having the capacity to shape the data collection instruments (the ARYS questionnaire or the interview guide used to collect interview data); as well, there was not an opportunity to enage in ‘real-time’ member-checking activities as the qualitative analysis unfolded, which might have been useful in light of the object of study (i.e., HIV/STI-related stigma is profoundly rooted in social norms).  While secondary analysis approaches allow for an efficient means of accessing data, there is a need to conduct additional, primary reseach to further empiricize questions pertaining to stigma and its influence on young people’s engagement within STI/HIV testing.  Secondly, the findings of this study point to the complexity of effectively tackling stigma. Given the complexities around tackling multiple layers and mechanisms of stigma, combination approaches to anti-stigma intervention should be considered, and future research to inform those interventions needs to account for opportunities at the micro-, meso- and macro-levels to decrease HIV/STI-related stigma among youth. Furthermore, while views on HIV/STI-related risky behaviours have evolved over time, double standards remain in how young men and women are stereotyped according to normative thinking pertaining to sexuality and young people. While novel approaches, such as online HIV/STI testing, may help address externalized notions of HIV/STI-related stigma among youth, the results of the current study show that online testing may not be 60  able to fully ameliorate the impacts of internalized HIV/STI-related stigma. Future research could focus on interventions to help young people alleviate or redirect internalized feelings of shame – alongside interventions that operate at a structural level to revise social norms regarding HIV/STI-related stigma. HIV/STI-related stigma, in concert with other forms of stigma (in particular ageism), continues to affect the HIV/STI testing and treatment practices of youth – and significant changes in normative thinking will be required in order to create spaces where all youth feel safe and comfortable when seeking HIV/STI-related care.  Additionally, prevention efforts should be tailored to meet the special needs of particular sub-populations of youth (e.g., those who are most marginalized). For example, tailoring interventions to meet the special needs of drug-using groups of youth can include paying special attention to the language used, training for clinicians regarding non-judgmental care provision, and adopting or advocating rights-based approaches to the provision of healthcare services. As well, stigma may be effectively addressed through interventions that take a sex-positive approach during counselling, care provision and other communication with youth (as opposed to approaches that focus on the adverse consequences of unhealthy sexual practices or the problem of young people avoiding HIV/STI care). Tailoring interventions, as opposed to a reliance on targeting interventions at those deemed as being at “high-risk” (which in and of itself can be stigmatizing) holds promise. 5.3 Conclusions While the understanding of HIV/STI-related stigma has expanded over the past three decades, the conceptualizations of the mechanisms of how HIV/STI-related stigma is experienced by young men and women, remains limited. Today’s young people are facing a unique set of circumstances – the epidemic threatens to re-escalate amongst some subgroups of youth (e.g., 61  young MSM), while HIV becomes increasingly recognized as a manageable chronic condition. Going forward, it is crucial to further understand the influence of multiple stigmas on the lives of young people, particularly on the lives of young PLHIV, in order to re-tool existing approaches to addressing HIV/STI-related stigma in more effective ways. 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(HIV or HIV1 or HIV2 or HIV infect* or human immunodeficiency virus or human immuno-deficiency virus or human immunedeficiency virus or human immune-deficiency virus or acquired immune-deficiency syndrome or acquired immunedeficiency syndrome or acquired immunodeficiency syndrome or acquired immuno-deficiency syndrome).ti,ab. 2.  (Stereotyp* or shame or social isolation or stigma* or social distanc* or social stigma* or discriminat* or prejudice or fear or attitude* or disclos*).ti,ab. 3.  (Youth or Young People or Adolescent* or Young population* or Youth population* or Young adult* or YLHIV or ALHIV).ti,ab. 4.  1 AND 2 AND 3 5.  limit 4 to English language 6.  limit 5 to yr="1997 -Current" 7.  remove duplicates from 6    


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