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The Cedar Project : understanding the sexual vulnerabilities of Indigenous young people who use drugs… Chavoshi, Negar 2017

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   THE CEDAR PROJECT: UNDERSTANDING THE SEXUAL VULNERABILITIES OF INDIGENOUS YOUNG PEOPLE WHO USE DRUGS IN BRITISH COLUMBIA, CANADA   by  Negar Chavoshi   MSc, The University of British Columbia, 2009 HBSc, University of Toronto, 2006    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF   DOCTOR OF PHILOSOPHY  in   THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (Population and Public Health)   THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)   August 2017  © Negar Chavoshi, 2017    ii Abstract Background: For Indigenous communities in Canada, the legacies of colonization have severely compromised sexual wellbeing. Indigenous leaders are growing increasingly concerned for the sexual health of their young people, particularly those who use drugs to cope with adversity. However, there is a critical gap in evidence pertaining to the complex and multifaceted relationships between intergenerational trauma, self-medication, and sexual wellbeing.  Methods: Data was gathered from the Cedar Project: an ongoing prospective cohort study of Indigenous young people who use drugs and live in British Columbia. A multidisciplinary approach was used to investigate historical and lifetime factors that impact sexual health. Epidemiological analyses were used to determine the prevalence and correlates of Herpes Simplex Virus-2 (HSV-2) and syphilis positivity among 250 participants. An interpretive thematic approach was used to qualitatively analyze in-depth interviews with 28 participants.  Results: The seroprevalence of HSV-2 among women and men was 79% and 36%, respectively. For women, HSV-2 positivity was associated with being taken away from biological parents, involvement in survival sex work, and injecting drugs. For men, having ever been in prison was significantly associated with HSV-2 positivity. Young men who stated that culture played an important role during their developmental years were less likely to test positive for HSV-2. A history of syphilis infection was observed among 21 participants, 95% of which occurred among women living in Vancouver. Results from the qualitative study highlighted how sexual health continues to be negatively impacted by intergenerational trauma stemming from the residential school and child welfare systems. Participants’ narratives demonstrated the protective effect of family and cultural connectedness on sexual wellbeing. Participants offered detailed recommendations on how to improve sexual health outcomes through culturally-safe and trauma-informed sexual health resources that are integrated with mental health and drug recovery programs aimed at supporting struggling families.   iiiConclusion: To support the sexual wellbeing of Indigenous young people who use drugs, the underlying causes of ongoing trauma and social marginalization must be urgently addressed. These findings call for the backing of Indigenous-led healing strategies that focus on young people’s inherent strengths, and use Indigenous wellness frameworks to promote collective healing.          iv Lay summary  This study aimed to identify factors that impact sexual wellbeing among Indigenous young people who use drugs in British Columbia. A multidisciplinary approach used qualitative and quantitative analytic methods to unravel the complex aspects of sexual health and how they are influenced by the legacies of colonization, systemic racism, social marginalization, and cultural resilience. This was accomplished by interviewing 28 participants and determining the prevalence and correlates of ulcerative STIs among 250 young men and women participating in the Cedar Project. The findings validated that Indigenous young people who use drugs are coping with unresolved traumas rooted in historical, social, and structural barriers to sexual wellbeing. The protective effects of strong connections to traditional culture were also reconfirmed. This study contributes to the capacity of Indigenous leaders and service providers to raise awareness, identify needs, and advocate for culturally-safe and trauma-informed sexual health resources that respect and integrate Indigenous values.               vPreface This statement is to confirm that the work presented in this dissertation was conceived, conducted, analyzed, and written by Negar Chavoshi (N.C.). N.C. designed the research program, established the research objectives and hypotheses, collected significant parts of the data, conducted all the data analyses, and wrote each chapter of this dissertation, all with the guidance of the Cedar Project Partnership and the thesis committee, which consisted of supervisor Dr. Patricia M. Spittal (P.M.S.), and members Drs. Martin T. Schechter (M.T.S.), David M. Patrick (D.M.P.), Chris G. Richardson (C.G.R.), and Shannon T. Waters (S.T.W.) The quantitative data presented in Chapters 4 and 5 were gathered by Cedar Project study staff located in Vancouver, Prince George, and Chase, British Columbia. The qualitative data presented in Chapters 6 and 7 were gathered by N.C. The interpretation of the study results presented in Chapters 4 through 7 was guided by the expertise of the Cedar Project Partnership, the Indigenous governance body that provides oversight to the totality of Cedar Project’s research, ethical, and knowledge translation activities. For the Recommendations and Conclusion chapter (Chapter 8), N.C. received guidance from S.T.W. (Stz'uminus First Nation), who is the Medical Director of Vancouver Island Health, Aboriginal Physician Advisor to the Provincial Health Officer, and a former Senior Medical Officer of the First Nations Health Authority. Guidance was received from Vicky Thomas (Wuikinuxv Nation), who has been involved with the Cedar Project as its Project Coordinator from the study’s inception. This research was approved by the Cedar Project Partnership. In addition, it was given ethics approval by Providence Healthcare and the University of British Columbia Research Ethics Board (Research Ethics Board certificate number: H11-01004).     vi Table of contents   Abstract .................................................................................................................................... ii Lay summary .......................................................................................................................... iv Preface ...................................................................................................................................... v Table of contents .................................................................................................................... vi List of tables............................................................................................................................ ix List of figures ........................................................................................................................... x Glossary .................................................................................................................................. xi Acknowledgements ............................................................................................................... xii Dedication ............................................................................................................................. xiii Chapter 1: Introduction, background, rationale, and objectives ....................................... 1 1.1 Background ................................................................................................................................. 1 1.1.1 The colonization of Indigenous people in Canada ................................................................ 1 1.1.2 Intergenerational trauma and the legacies of colonization .................................................... 3 1.1.3 The sexual health of Indigenous communities in Canada ..................................................... 5 1.1.4 Increased vulnerability to sexually transmitted infections among Indigenous people in Canada ............................................................................................................................................ 7 1.2 Cultural resilience .................................................................................................................... 10 1.3 Rationale .................................................................................................................................... 11 1.4 Conceptual framework ............................................................................................................ 14 1.5 Objectives .................................................................................................................................. 17 1.6 Overview of dissertation .......................................................................................................... 19 Chapter 2: Literature review ............................................................................................... 20 2.1 Contextualizing sexual health within a historical trauma paradigm .................................. 20 2.1.1 Colonization and the erosion of sexual health for Indigenous communities ...................... 20 2.1.2 The impact of sexual abuse on sexual wellbeing ................................................................ 23 2.1.3 The ongoing impacts of colonization on the sexual health of Indigenous women ............. 27 2.1.4 Social marginalization and accessing resources, treatment, and care ................................. 30 2.2 Vulnerability to sexually transmitted infections among Indigenous people in Canada .... 32 2.2.1 Condom use among Indigenous people .............................................................................. 32 2.2.2 Sexual health education, perceptions, and attitudes among Indigenous young people ...... 36 2.2.3 The epidemiology of HIV/AIDS, HSV-2 and syphilis among Indigenous people in Canada ...................................................................................................................................................... 39 2.2.4 The epidemiology of HIV/AIDS, HSV-2 and syphilis among Indigenous women in Canada .......................................................................................................................................... 41 2.3 Drug use and sexual health risks ............................................................................................. 43 2.3.1 The association between substance dependence and STI risk among Indigenous people .. 43 2.3.2 Ulcerative STIs among people who use drugs in the general population ........................... 44 2.4 Ulcerative sexually transmitted infections and HIV seroconversion ................................... 46 2.4.1 The association between HSV-2 and HIV seroconversion ................................................. 46 2.4.2 The association between syphilis and HIV seroconversion ................................................ 48  vii2.4.3 STI management for HIV prevention ................................................................................. 49 2.5. Summary of the literature ...................................................................................................... 50 Chapter 3: Methodology ....................................................................................................... 53 3.1. The Cedar Project’s ethical considerations .......................................................................... 53 3.1.1 Partnership with Indigenous collaborators .......................................................................... 53 3.1.2 Confidentiality and participant care .................................................................................... 56 3.1.3 Follow-up care .................................................................................................................... 57 3.2 The Cedar Project’s study design, setting, and questionnaires ............................................ 59 3.2.1 Cedar Project setting ........................................................................................................... 59 3.2.2 Cedar Project study design .................................................................................................. 61 3.2.3 Cedar Project questionnaires ............................................................................................... 62 3.3 Dissertation methods ................................................................................................................ 64 3.3.1 Rationale for selecting syphilis and HSV-2 as biomarkers for sexual vulnerability .......... 65 3.3.2 Quantitative data collection ................................................................................................. 66 3.3.3 Quantitative data analysis ................................................................................................... 67 3.3.4 Qualitative data collection ................................................................................................... 69 3.3.5 Qualitative data analysis ..................................................................................................... 75 Chapter 4: The prevalence and correlates of Herpes Simplex Virus 2 in a cohort of Indigenous young people who use drugs in British Columbia, Canada .......................... 77 4.1 Introduction .............................................................................................................................. 77 4.2 Methods ..................................................................................................................................... 79 4.2.1 The Cedar Project study design ........................................................................................... 79 4.2.2 Data collection .................................................................................................................... 80 4.2.3 Statistical analysis ............................................................................................................... 81 4.3 Findings ..................................................................................................................................... 84 4.3.1 HSV-2 seropositivity among women .................................................................................. 85 4.3.2 HSV-2 seropositivity among men ....................................................................................... 86 4.4 Discussion .................................................................................................................................. 93 Chapter 5: The prevalence and correlates of syphilis positivity among Indigenous young people who use drugs in British Columbia ....................................................................... 107 5.1 Introduction ............................................................................................................................ 107 5.2 Methods ................................................................................................................................... 108 5.2.1 The Cedar Project study design ......................................................................................... 108 5.2.2 Data collection .................................................................................................................. 109 5.2.3 Statistical analysis ............................................................................................................. 110 5.3 Findings ................................................................................................................................... 112 5.4 Discussion ................................................................................................................................ 118 Chapter 6: “Sex itself is one thing, but there’s so much more to it”: Indigenous young people’s voices on sexual experiences, education, and safety .......................................... 128 6.1 Introduction ............................................................................................................................ 128 6.2 Objectives and rationale ........................................................................................................ 131 6.3 Review of study setting, theoretical framework, and participants .................................... 132 6.4 Data collection and analysis ................................................................................................... 133 6.4.1. Data collection ................................................................................................................. 133 6.4.2 Analytic approach ............................................................................................................. 135 6.5 Findings ................................................................................................................................... 136 6.5.1 Intergenerational trauma ................................................................................................... 138 6.5.2 Sexual abuse ...................................................................................................................... 142  viii 6.5.3 Sexual education ............................................................................................................... 149 6.5.3 The “intangible” components of sex ................................................................................. 165 6.5.4 Drug use and sexual health ............................................................................................... 175 6.6 Discussion ................................................................................................................................ 180 Chapter 7: “Here’s what we need…”: Indigenous young people’s voices and wisdom on how to support sexual wellbeing ........................................................................................ 200 7.1 Introduction ............................................................................................................................ 200 7.2 Data collection methods ......................................................................................................... 203 7.3 Analytic approach .................................................................................................................. 205 7.4 Findings ................................................................................................................................... 206 7.4.1 Safe homes ........................................................................................................................ 207 7.4.2 Enhancing sexual education .............................................................................................. 210 7.4.3 Building upon community strengths ................................................................................. 215 7.4.4 An effective healthcare system ......................................................................................... 219 7.4.5 Mental health provision ..................................................................................................... 223 7.4.6 Boosting self-esteem ......................................................................................................... 226 7.5 Discussion ................................................................................................................................ 229 Chapter 8: Conclusions and recommendations ............................................................... 247 8.1 Summary of findings .............................................................................................................. 247 8.2 Strengths and unique contributions ...................................................................................... 255 8.3 Community relevance ............................................................................................................ 259 8.4 Limitations .............................................................................................................................. 277 8.5 Conclusions ............................................................................................................................. 279 Works cited .......................................................................................................................... 281              ixList of tables Table 4. 1: Comparison of demographic and traumatic life events among women who tested positive for HSV-2 (n=113) vs. women who tested negative (n=30); and men who tested positive for HSV-2 (n=39) vs. men who tested negative (n=68) ............. 87	   Table 4. 2: Comparison of sexual vulnerabilities among women who tested positive for HSV-2 (n=113) vs. women who tested negative (n=30); and men who tested positive for HSV-2 (n=39) vs. men who tested negative (n=68) .............................................. 88	   Table 4. 3: Comparison of drug related vulnerabilities among women who tested positive for HSV-2 (n=113) vs. women who tested negative (n=30); and men who tested positive for HSV-2 (n=39) vs. men who tested negative (n=68) ..................... 90	   Table 4. 4: Model 1: Correlates of testing HSV-2 positive among the young women participating in the Cedar Project (n=106) ................................................................ 92	   Table 4. 5: Model 2: Correlates of testing HSV-2 positive among the young women participating in the Cedar Project (n=143) ................................................................ 92	   Table 4. 6: Correlates of testing HSV-2 positive among the young men participating in the Cedar Project (n=98) .............................................................................................. 92	   Table 5. 1: Comparison of demographic and traumatic life events among women living in Vancouver with a history of syphilis (n=20) vs. women without (n=38) ........... 114	   Table 5. 2: Comparison of sexual vulnerabilities among women living in Vancouver with a history of syphilis (n=20) vs. women without (n=38) ................................... 115	   Table 5. 3: Comparison of drug related vulnerabilities among women living in Vancouver with a history of syphilis (n=20) vs. women without (n=38) ................ 117	          x List of figures  Figure 1: Conceptual framework: "Indigenist" Stress Coping Model (Walters & Simoni, 2002) ................................................................................................................. 16	                        xiGlossary  AIDS Acquired Immune Deficiency Syndrome  BCCDC British Columbia Centre for Disease Control Cultural-safety A care model that incorporates power imbalances, decolonization and self-determination within a framework that includes – but extends beyond – cultural sensitivity and competence (Health Council of Canada, 2012) Decolonization The act of reversing the legacies of colonization by 1) recognizing the past and present impacts of forced assimilation and 2) pursuing self-determination and healing through the rediscovery of ancestral traditions, teachings, and values (Aquash, 2013)  DTES The Downtown Eastside neighbourhood of Vancouver, BC, Canada  HCV Hepatitis C Virus  HIV Human Immunodeficiency Virus HSV-2 Herpes Simplex Virus type 2  Indigenous Person A descendant of the First Nations Peoples of North America; including Indigenous, Aboriginal, Métis, First Nations, Inuit, and Status and non-Status Indians INSITE  Vancouver’s supervised injection site Intergenerational trauma   The cyclical effects of collective emotional and psychological injuries stemming from colonization that extend over multiple generations (Yellow Horse & Brave Heart, 2004) IV Intravenous  On/Off-reserve Living on or off a reserve, which is a tract of land, the legal title to which is held by the Crown, set apart for the use and benefit of an Indigenous band (Indigenous and Northern Affairs, Canada) Trauma-informed care A western term to describe the traditional style of healthcare that has always been practiced by Indigenous knowledge keepers. This care model recognizes trauma, understands its impact and prevalence, and responds to it through healing processes that do not re-victimize the care recipient (Schladale, 2013). Sex-ed Formal sexual education curriculum obtained at school STDs/STIs Sexually Transmitted Diseases/Infections  xii Acknowledgements First and foremost, I extend my gratitude to the powerful young men and women who participate in the Cedar Project. You entrusted me with your voices, and I hope I have done right by each and every single one of you. I am indebted to Dr. Patricia Spittal for giving me the tremendous privilege of being part of the Cedar Project team, and for supporting and advising me not only as a student, but as a friend. I would like to thank Drs. Chris Richardson, David Patrick, Shannon Waters and Martin Schechter for their encouragement, support, and guidance. Special thanks to Vicky Thomas for her wisdom and for teaching me how to find humility in research. I extend my sincere thanks to the wonderful staff at all three Cedar Project offices for coordinating my research efforts and advocating for participation. I could not have done this without you.  I would like to thank the Canadian Institutes for Health Research, the University of British Columbia, Kloshe Tillicum, Environments for Aboriginal Health Research Networks BC, and the Social Research Centre for HIV Prevention for funding this work.  My amazing parents, I owe you all my happiness. You sacrificed all you knew to give us a chance, and I hope that I have made you proud. My little sunshine, Mahssa, you give me warmth and the will to grow. #slay. My wonderful husband, Carl, thank you for filling my heart with love, assurances, and for believing in me when I didn’t believe in myself. Noushins, my bestest, thank you for always knowing how to make me smile. Pearlie, “eye of the tiger”! Binoo, my soul sister, thank you for always being in my corner and letting me just be me. Mum and Dad Kapadia, thank you for giving me the gift of another set of parents to be loved by. Remy and Zola, thank you for being my therapeutic furbabies. I love you all to bits.        xiiiDedication For my father, who has addressed me as “Dr. Chavoshi” since I was 6.                                            1 Chapter 1: Introduction, background, rationale, and objectives  1.1 Background  1.1.1 The colonization of Indigenous people in Canada  The colonization of Indigenous people in Canada is one of the darkest chapters in the nation’s history. Since laying claim to its Eastern shores over 500 years ago, British and French invaders aggressively enforced political, ideological, and economic agendas to assimilate Indigenous peoples and control their resources. The first barriers to survival that were erected by European colonizers included forced removal from traditional lands, economic and social deprivation, and cultural genocide (Red Road HIV/AIDS Network, 2006). Over the span of the last two centuries, numerous treaties and legislations have directly targeted the self-determination and wellbeing of Indigenous people (Truth and Reconciliation Commission of Canada (TRC), 2015; Wesley-Esquimaux & Smolewski, 2004). The most destructive of all was the Gradual Civilization Act of 1857, which formed the church-state partnership that created the residential school system. The first schools opened in the late 1840s. By the 1870s, the Indian Act mandated that all Indigenous children attend residential schools, many of which were hundreds of miles away from their native communities (Milloy, 2008). Over the span of 150 years, more than 150,000 Indigenous children were forcibly removed from their families and placed into institutions with the sole intent to “kill the Indian and save the man” (Fournier & Crey, p. 55).  The official agenda of the residential school system was to eradicate Indigenous ways of living. This was attempted by obstructing the intergenerational transmission of Indigenous knowledge systems and by imbuing a deep sense of shame, hatred, and  2 embarrassment in Indigenous identity. Traditional ceremonies were criminalized, students were physically punished if they acknowledged their culture, and were forcibly indoctrinated into European and Christian ways of living. By 1920, the Deputy Minister of Indian Affairs assured that the continued existence of the schools would exterminate Indigenous people as an identifiable group within the next hundred years (Fournier & Crey, 1997; Milloy, 1999; Royal Commission of Aboriginal Peoples (RCAP), 1996; TRC, 2015).  The residential schools were incompetently managed and subjected children to abhorrent living conditions. Poor sanitation, malnutrition, and overcrowding resulted in staggering death tolls. A government medical inspector estimated that a quarter of all Indigenous children attending residential school died, and many more succumbed to disease after being sent home (Milloy, 1999, p. 49). While forced assimilation operated under the pretense of providing Indigenous children with training that would ready them for modern “civilization”, only a minimal level of schooling that focused on manual and domestic labour was provided. In truth, the schools utilized child labour to maintain their upkeep in what was known as the “half-day system”, effectively neglecting every aspect of students’ developmental needs (Legacy of Hope Foundation, 2013, p. 15).  The most damaging legacy of the residential schools was the rampant sexual abuse committed by the unchecked figures of authority who preyed upon the children in their care. As a result of “institutionalized pedophilia”, almost every child in the system experienced some form of sexual abuse (Fournier & Crey, 1997, p. 72). Many of the perpetrators were the very religious figures who preached chastity, sexual abstinence, heterosexuality, and monogamy. This caused serious confusion among victims with  3 regard to the dynamics of sexual relationships and the meaning attached to sex (Fournier & Crey, 1997, p. 129; Milloy, 1999, p. 296). Abuse coupled with the disruption of fundamental familial ties that nurture the development of a child’s psyche caused severe harm. The “graduates” of residential schools entered society with deeply unresolved trauma, self-shame, and broken identities. This in turn gave way to the devastating consequences of intergenerational trauma (Aboriginal Healing Foundation, 2007).  1.1.2 Intergenerational trauma and the legacies of colonization In the residential schools, total adult control reigned and abuse was treated as a method of child rearing. Without positive role models and familial kinships to mirror, many residential school survivors had very limited knowledge about the dynamics surrounding family interactions. The burden of guilt, shame, and anger that survivors brought home with them interfered with their ability to easily reconnect with families and communities (LaFrance & Collins, 2003; TRC, 2015). As the traditional cultural values that mediated against vulnerability had eroded, many residential school survivors unintentionally replicated the cycles of abuse at home (Barlow, 2003; Chester et al., 1994; Yellow Horse Brave Heart, 2003). The unhealed wounds that subjected Indigenous people to inescapable cycles of pain, led to the lateral transmission of trauma like a “disease ripping through our communities” (Grand Chief Edward John, 1992, from Milloy, 1999, p. 295). Indigenous scholars describe this cyclical effect of collective emotional and psychological injuries that extends over multiple generations as intergenerational trauma (Yellow Horse & Brave Heart, 2004).  The legacies of the residential schools had resulted in “alienation, poor self-concept and lack of preparation for independence, for jobs and for life in general”  4 (Kirkness, 1992, p.12). Many survivors found it challenging to succeed in the racist society that awaited them. Consequently, families struggling with poverty, ongoing marginalization, and unresolved trauma found it extremely difficult to create safe homes for their children (Chansonneuve, 2007; LaRocque, 1994; Tousignant & Sioui, 2009). In the 1940’s, the Canadian government concluded the residential schools to be costly and ineffective, and began winding them down (TRC, 2015). Eventually, child welfare was transferred from federal to provincial agencies in the 1950’s, and ascribed to a per capita funding model that incentivized the long-term removal of Indigenous children from what were deemed “unfit” homes. A new era of dislocation, known as the “60’s scoop”, separated thousands of children from their families, communities, and culture, creating a new wave of collective pain (Blackstock & Trocmé, 2004; Fournier & Crey, 1997, p. 30; TRC, 2015; Trocmé et al., 2006). As the factors contributing to child apprehension - namely poverty, inadequate housing, and self-medication - remained unaddressed in Indigenous communities, the number of Indigenous children entering the foster care system grew substantially (Blackstock & Trocmé, 2004). By 1980, Indigenous children were six times more likely to be apprehended from their homes than non-Indigenous children (Durst, 2002). In 2011, while Indigenous children comprised only 7% of children under 14 in Canada, they represented 48% of all children in foster care (Statistics Canada, 2016).  The last residential school closed in 1996 (TRC, 2015). As survivors started stepping forward to disclose their harrowing experiences, apologies from the state and church were followed by criminal charges and class action suits (TRC, 2015). Today,  5 over 80,000 residential school survivors are still living, 35,000 of whom reside in British Columbia (BC) (Aboriginal Healing Foundation, 2007).  Indigenous scholars and leaders maintain that the legacies of the residential school systems continue to be iterated by the dismantling of Indigenous families and ways of living through the child welfare system (Christian, 2010; Fournier & Crey, 1997). The forcible apprehension of children continues to sever sacred familial and communal ties, depriving children of their cultural identity, and contributing to new cycles of intergenerational trauma. The long term mental health effects of the residential school system and child welfare systems are very much alive, manifesting as Post-Traumatic Stress Disorder, depression, self-medication, and suicide (Corrado & Cohen, 2003; Public Health Agency of Canada, 2006; Monirruzaman et al., 2009; Yellow Horse Brave Heart, 2003).  1.1.3 The sexual health of Indigenous communities in Canada   The legacies of colonization have particularly impacted the sexual wellbeing of Indigenous people and communities (Farmer et al., 1996; Vernon, 2001; TRC, 2015). The widespread sexual abuse that was inflicted upon Indigenous children in residential schools was combined with enforced silence. The colonizers further attacked the wellbeing of Indigenous people by attempting to eradicate the traditional values and cultural practices that safeguarded their sexual health for thousands of years (Bopp & Bopp, 1997). Consequently, many survivors were left to grapple with the long-term consequences of sexual abuse alone and received little to no support to restore their mental, emotional, physical, and spiritual wellness. This prevented healing and resulted  6 in the transmission of trauma through successive generations (Chansonneuve, 2007; Milloy, 1999; TRC, 2015).  To numb the immense pains of self-loss, some survivors turned to drugs and alcohol to cope (Chansonneuve, 2007; Gesink et al., 2016; Kendler et al., 2000). As drug use is associated with negative sexual health outcomes (Chavoshi et al., 2012; Devries, Free, & Jategaonker, 2007; First Nations Information Governance Committee, 2012; Kotchick et al., 2002), intergenerational trauma is directly impacting sexual vulnerability by way of self-medication with illicit drugs. These risks are intensified by a lack of sexual education in many Indigenous homes and communities. The legacies of the residential schools have made sexual discourse extremely difficult (Myers et al., 1999). The silence, stigma, and shame that has been historically attached to sexual matters jeopardizes the ability of many Indigenous young people to acquire critical sexual health information. Such risks are compounded by inadequate and/or inaccessible sexual health resources in rural or remote areas (Andersson et al., 2008; Yee, 2010). Consequently, many young people are left to learn about sex from self-exploration, media, peers, and even through sexual abuse (LaRocque, 1994, p. 80).  Communities are actively resisting the adversities that have been placed before them, and leaders are rigourously prioritizing the sexual health needs of young people. However, the barriers to sexual safety, health, and education are deeply embedded in the histories of colonization and continue to interfere with sexual wellbeing (Yee, 2010). The culmination of these factors has led Indigenous young people to experience high rates of unplanned pregnancies (Health Canada, 2001), teenage pregnancies (Cloe & Guimond, 2009; UNICEF Canada, 2009), inconsistent condom use (Chavoshi et al., 2012; Heath et  7 al., 1999; Shercliffe et al., 2007; Spittal et al., 2002; Weber et al., 2003), and STIs (Rotermann, 2005; Steenbeck et al., 2006). However, when such health disparities are reported in isolation, it can reinforce negative stereotypes toward Indigenous people and discrimination against them, and perpetuate self-blame within communities (Larkin et al., 2007; Health Canada, 1998). The World Health Organization (2006) defines sexual health as: “A state of physical, emotional, mental and social wellbeing in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled” (Chapter 3, p. 4).  As the aforementioned requirements to sexual wellbeing have been grossly compromised amongst Indigenous people, their sexual health outcomes must be interpreted within the context of the lifetime and intergenerational traumas that stem from the consequences of colonization.   1.1.4 Increased vulnerability to sexually transmitted infections among Indigenous people in Canada  The term sexual vulnerability is used to describe the disproportionate sexual health risks that Indigenous communities face. This concept locates any/all of the lifetime experiences that impact sexual health within a framework that accounts for the historical traumas that Indigenous people are living with.  Sexually transmitted infections (STIs) are considered to be effective biomarkers  8 for sexual vulnerability (Gallo et al., 2013; Weller & Davis, 2005). STI morbidity not only takes a detrimental physical toll, it can also devastate mental and emotional health by diminishing one’s self-concept (Newton & McCabe, 2008). Ulcerative STIs such as syphilis and Herpes Simplex Virus Type-2 (HSV-2) are associated with HIV seroconversion (Galvin & Cohen, 2004; Centers for Disease Control and Prevention, 1998). Many Indigenous communities have tightly knit sexual networks, which allow STIs to spread rapidly even in the most geographically isolated areas (Wylie & Jolly, 2001). Consequently, Indigenous leaders and service providers are extremely concerned for the present and future health of their communities.  Statistics Canada (2003) reports that Indigenous people between the ages of 15-24 are 2.5 times more likely to acquire STIs when compared to non-Indigenous Canadians of the same age (Rotermann, 2005). The Public Health Agency of Canada (2010a) estimates that the rate of chlamydia among First Nations people is seven times that of the general population, and research has demonstrated that one in five chlamydia cases occurs among Indigenous people (Sevigny et al., 2003). An investigation of a gonorrhea outbreak in Northern Alberta reported that Indigenous people constituted 96% of cases (De et al., 2003), and were 2.6 times more likely to become reinfected when compared to non-Indigenous people who had contracted gonorrhea (De et al., 2007). Among street youth, Indigenous people are twice as likely to test positive for chlamydia (Shields et al., 2004).  Indigenous people also bear a disproportionate portion of Canada’s HIV/AIDS burden. In 2011, they comprised 3.8% of the general population, but constituted almost 9% of all prevalent HIV infection cases and were 3.5 times more likely to be newly infected with HIV. The rates of HIV cases among Indigenous young people, women, and  9 people who use intravenous drugs are markedly higher than the rates for the same subgroups among other ethnicities (Public Health Agency of Canada, 2015). International research has established that ulcerative STIs such as HSV-2 and syphilis increase the risk of HIV seroconversion by two- to three-fold (Freeman et al., 2006; Wald et al., 2002). Genital herpes is the second most prevalent STI in Canada and the most common cause of genital ulceration (British Columbia Centre for Disease Control (BCCDC), 2009). The prevalence of HSV-2 among Indigenous people in Canada is unknown. However, one study among STI clinic attendees in two Canadian cities reported the rate of HSV-2 infection among Indigenous patients to be 2.6 times higher than that of non-Indigenous patients (Singh et al., 2005). In 2013, the Annual Summary of Reportable Diseases in British Columbia identified that Indigenous people accounted for 9.1% (n=277) of the province’s newly reported syphilis cases between 2004-2013, despite constituting only 5% of the population (BCCDC, 2013). Reports from syphilis outbreaks in the Western provinces of Canada also demonstrated that a disproportionate rate of syphilis infections occurred among Indigenous people (CBC, 2010; CBC, 2015a; Government of Alberta, 2010; Ogilvie et al., 2009).  As mentioned, the legacies of colonization have disproportionately burdened Indigenous communities with drug and alcohol dependence (First Nations Information Governance Committee, 2012). Drug use is associated with increased vulnerability to STIs (Devries et al., 2009a; Marshall et al., 2009; Ship & Norton, 2001). Yet, there is a paucity of literature pertaining to the complex interactions between historical trauma, self-medication, and sexual risk among Indigenous people in Canada. We must therefore look to data from the general population to understand sexual health risks due to drug  10 use. The literature demonstrates that people who use drugs are more likely to have multiple sex partners, be involved in survival sex work, and have sex with partners who use injection drugs (Booth et al., 2000; Booth et al., 2007; Irwin et al., 1993). Studies have reported that HSV-2 and syphilis infection rates among populations who use drugs are significantly higher than that of the general population (De Jarlais et al., 2010; Xu et al., 2006). For Indigenous people who use drugs, any sexual health risks due to drug use will be compounded by historical trauma, systemic racism, and social marginalization. However, their ramifications are not well investigated for Indigenous young people who use drugs. 1.2 Cultural resilience   Indigenous people have long been aware of their health needs and have a profound ability to overcome barriers to wellness. Despite 500 years of colonization, Indigenous communities continue to demonstrate their inherent strengths and cultural resilience by exercising resistance in the face of adversity. Indigenous authors and Elders emphasize that resilience is a cultural strength that mediates against adversity by acting as a psychological buffer against trauma stressors (Henderson, 2008; Kirmayer et al., 2003; McIvor et al., 2009; Walters & Simoni, 2002; Wexler et al., 2014).  The protective quality of cultural resilience on health outcomes has been established across Indigenous communities in North America (Devries et al., 2009a; Dion-Stout et al., 2001; Gesink et al., 2016; Kirmayer et al., 2003; Korhonen & Ajunniginiq, 2006; Lavallee & Clearsky, 2006; Wexler et al., 2014). Andersson and Ledogar’s (2008) study among 622 Indigenous people in Manitoba found that young people who participated in traditional ceremonies had increased emotional competence,  11 and were less likely to drink alcohol or become involved in crime. Alcohol cessation was also observed among Indigenous adults who participated in traditional ceremonies and Indigenous spirituality in four American Indian reservations and five First Nations reserves in Canada (Torres Stone et al., 2006). One seminal study across 196 Indigenous bands in BC demonstrated that communities who engage in cultural continuity - which includes self-governance, preserving/renewing traditions, and speaking traditional languages - have drastically lower suicide rates (Chandler & Lalonde, 1998). In a prospective cohort study of Indigenous young people who use drugs in BC (the Cedar Project), participants who spoke their traditional language demonstrated higher resiliency, and living by traditional culture was shown to significantly decrease psychological distress (Pearce, 2014).  While forced assimilation obstructed the intergenerational transmission of Indigenous teachings about sexual matters, many Indigenous traditions, beliefs, ceremonies, and languages survived the devastations of colonization and continue to function as healing instruments (Gesink et al., 2016). Indigenous young people are reconnecting with their heritage (Statistics Canada, 2013), but those who have migrated to urban areas are often disconnected from their communities, families, and culture and may not readily access the therapeutic benefits of traditional practices (Fleming & Ledogar, 2008).  1.3 Rationale  The dearth of Indigenous-steered knowledge pertaining to the health of Indigenous people in Canada has been recognized (De et al., 2007; Law et al., 2008). This paucity of research led to the development of the Cedar Project, an Indigenous  12 governed initiative addressing the health risks of Indigenous young people who use illicit injection and non-injection drugs in Vancouver, Prince George, and Chase, BC. Since 2003, the Cedar Project has provided Indigenous leaders with the epidemiological evidence base necessary to support meaningful public health interventions that reduce HIV and Hepatitis C (HCV) vulnerability among their young people. Indigenous collaborators and investigators, collectively known as the Cedar Project Partnership, have governed the entire research process and assure adherence to decolonizing research principles and ethical codes of conduct. Knowledge translation and community engagement is a hallmark of the Partnership. To our knowledge, the Cedar Project is the only cohort study of its kind globally. The focus of the Cedar Project has largely centered on injection drug use related health risks. The Cedar Project now aims to better understand other determinants of infectious diseases, including the lifetime experiences and risk/protective mechanisms that impact vulnerability to ulcerative STIs that are associated with HIV seroconversion.  To date, no known studies have examined the prevalence of and risk factors for syphilis or HSV-2 infection among Indigenous people who use drugs in Canada. The asymptomatic nature of ulcerative STIs raises concerns not only for people who remain untreated for life threatening yet controllable infections, but for the risks posed to their partners and to the neonates of pregnant women (BCCDC, 2007). Reporting ethnicity is not always mandated with STI testing, and the scale of morbidity is unknown. Inadequate access to and uptake of sexual health resources remains an ongoing challenge for many Indigenous people (First Nations Health Authority, 2013). Yet, there is very little  13 understanding of the specific mechanisms through which sexual health, education, and service utilization are influenced for Indigenous young people who use drugs in Canada. The Indigenous Partnership that governs the Cedar Project identified the need for a multidisciplinary exploration of sexual wellbeing that centres the voices of Indigenous young people who face adversity. Such a study can shed much needed light on the historical and lifetime factors that are impacting the sexual health and experiences of Indigenous young people who use drugs, and is fundamental to the strengthening and development of meaningful sexual health resources. To address this need, this project extended routine HIV and HCV testing among Cedar Project participants to include syphilis and HSV-2. The study non-invasively detected life-long exposure to two ulcerative STIs to help investigate the determinants of sexual vulnerability within a historical trauma and cultural resiliency framework. To contextualize the epidemiological investigations of HSV-2 and syphilis positivity, the various systems and factors that impact the sexual knowledge, behaviours, and health of Indigenous people who use drugs were explored through in-depth interviews with Cedar Project participants. Using both qualitative and quantitative methodologies can provide critical information to help unravel the complex intersections that shape understandings of, and experiences with sex and sexual health from childhood onwards (Stark & Trinidad, 2007).  Lastly, this study aimed to address Indigenous leaders’ concerns about the inadequacies of relevant sexual health programming and resources for their young people (Banister & Begoray, 2011; Clark & Hunt, 2011; Yee, 2010). The Public Health Agency of Canada (2008) describes sexual health as “a key aspect of personal health and social welfare that influences individuals across their life span”, and has long recognized that  14 Indigenous people require new and effective approaches to sexual programming that are relevant to their communities, histories, and values (p. 2). The sexual health resources that are available to Indigenous young people who use drugs are often not culturally-safe, fail to take histories of trauma into account (Craib et al., 2003), and are not informed by the very population they aim to serve.  To address these deficiencies, participants’ opinions and recommendations were sought on how to design and enhance sexual health resources tailored to Indigenous young people who use drugs. Cedar Project participants continually demonstrate strength and resistance in the face of the cumulative historical and lifetime adversities they face, and their voices will offer invaluable insight into the tools they deem necessary for sexual wellbeing. Indigenous leaders advise that strengths-based approaches at the individual, family, and community levels can successfully support the pursuit of wellness (The First Nations Health Authority, 2013). Accordingly, the primary goal of this study was to contribute to Indigenous service providers’ capacity to raise awareness, identify needs, advocate for adequate sexual risk prevention, and develop a sexual health strategy that respects and integrates Indigenous values and strengths.  1.4 Conceptual framework This study’s framework is informed by theories that account for the cumulative consequences of colonization, forced assimilation, and historical injustices that span over centuries (Chansonneuve, 2005; Fournier & Crey, 1997; Wesley-Esquimaux & Smolewski, 2004). Any examination of the current sexual health of Indigenous people in Canada must examine the historical and intergenerational impacts of the residential school and child welfare systems (Fournier & Crey, 1997, p. 81). The disproportionate  15 sexual health risks that Indigenous communities face can only be fully understood by reflecting on the interrelated effects of attempted cultural genocide, ongoing social marginalization, familial fragmentation, poverty, self-medication, and hopelessness. Indigenous scholars stress that Indigenous people who use drugs do so to cope with unresolved trauma and ongoing pain (Walters & Simoni, 2002). Such social disparities and any associated coping strategies drive the health of communities and situate present day outcomes within a social ecological framework (Farmer et al., 1996; Vernon, 2001). We must emphasize that the chosen framework does not place blame on any person or community, but rather, centres the voices of Indigenous people to contextualize health outcomes within legislations that aimed to eradicate Indigenous cultures, traditions, values, identities, and self-determination (Brown & Sterga, 2005; Kovach, 2010).  The theoretical framework of this study is also informed by research paradigms that recognize the inherent strengths and cultural resilience of Indigenous people (Dion-Stout et al., 2001; Kirmayer et al., 2011). Indigenous scholars, Karina Walters and Jane Simoni, offer an “Indigenist stress coping model” (Figure 1) to researchers who examine HIV vulnerability among Indigenous young people who use drugs. This model explains that young Indigenous people use “cultural buffers” to cope with collective and individual trauma and stressors. These buffers include traditional ceremonies, spirituality, and healing strategies that mediate between lifetime adversities and negative health outcomes by “strengthening psychological and emotional health, decreasing substance use, and mitigating the effects of the traumatic stressors” (Walters & Simoni, 2002, p. S105).   16 Indigenous scholars and Elders maintain that traditional practices, teachings, ceremonies, and spirituality are the foundations of strength and resilience among Indigenous people (Brant Castellano, 2008; Brass, 2009; Kirmayer, Brass, & Tait, 2000). Luthar et al. (2000) define resilience as a “dynamic process encompassing positive adaptation within the context of significant adversity” (p. 543). Ungar (2008) explains that the ability to exercise resilience is highly dependent on the presence and quality of social and environmental resources that are available to individuals who face adversity. Therefore, the capacity for resilience among Indigenous young people who use drugs considers both their inherent strengths and the use of cultural mediators that mitigate against negative health outcomes, while recognizing the historical, institutional, and structural barriers that interfere with wellness. Figure 1: Conceptual framework: "Indigenist" Stress Coping Model (Walters & Simoni, 2002)   17 1.5 Objectives The following study is a research endeavour between the Cedar Project Partnership and the researcher. Meetings with the Partnership affirmed that understanding participants’ lived experiences and the pathways to sexual wellbeing and vulnerability are critical to generating recommendations on how to best support the sexual health of young Indigenous people who use drugs in Canada. In numerous consultations with the Partners, this dissertation aimed to examine the following objectives and hypotheses:  O1: Quantify the prevalence of HSV-2 and syphilis antigen positivity among young Indigenous people who use drugs as a biomarker of sexual vulnerability.  H1.1: Self-reported STI rates will be lower than laboratory-based diagnosed rates. H1.2: Women are more likely to test positive for both HSV-2 and syphilis than men. O2: Determine the protective and risk factors associated with HSV-2 positivity for young Indigenous men and women who use drugs.  H2.1: Participants who test positive for HSV-2 are more likely to be involved in survival sex work. H2.2: Participants who test positive for HSV-2 are more likely to have survived intergenerational trauma (e.g. sexual abuse, foster care, parents in residential school) H2.3: Participants who test positive for HSV-2 are more likely to have used injection drugs. H2.4: Women will have more independent risk factors associated with HSV-2 seropositivity than men.   18 O3: Determine the protective and risk factors associated with syphilis antigen positivity among young Indigenous men and women who use drugs. H3.1: Participants who test positive for syphilis are more likely to be involved in survival sex work. H3.2: Participants who test positive for syphilis are more likely to have survived intergenerational trauma (e.g. sexual abuse, foster care, parents in residential school) H3.3: Participants who test positive for syphilis are more likely to have used injection drugs. O4: Qualitatively investigate how Indigenous young people who use drugs conceptualize their sexual realities; explore how they understand sexual health risks; and examine the role of historical and other individual, social, cultural, and protective factors in sexual development, education, experiences, behaviours, relationships, and health.  H.4.1: Lifetime trauma will be associated with past and present day challenges with respect to sexual health.  H.4.2: Lifetime access to resources that facilitate positive health outcomes, such as cultural connectedness, stable housing, and family ties will be associated with sexual wellbeing. O5: Seek recommendations from Indigenous people who use drugs on how to best support the sexual wellbeing of Indigenous you people who face lifetime adversities similar to their own by identifying protective factors and barriers to accessing and utilizing sexual health services/resources.  19 1.6 Overview of dissertation  This dissertation consists of eight chapters. Chapter 2 reviews the research literature pertaining to the sexual health of Indigenous people in Canada. Chapter 3 describes the methodological procedures undertaken for this entire study. The study uses an epidemiological and qualitative approach to consecutively address the aforementioned research objectives in Chapters 4 through 7. These four chapters were written as manuscript articles that will be submitted to peer-reviewed journals with the intent of publication. As such, the chapters will contain some repetition of methodology, historical context, and other background information pertinent to the study’s rationale. Chapter 8 summarizes the findings of chapters 4, 5, 6 and 7, discusses the study’s strengths and limitations, and offers recommendations for programming, policy, and intervention.              20 Chapter 2: Literature review  2.1 Contextualizing sexual health within a historical trauma paradigm  2.1.1 Colonization and the erosion of sexual health for Indigenous communities  Indigenous leaders stress that any discussion of Indigenous health in Canada must situate present day outcomes within the occurrence of intergenerational traumas that are rooted in forced assimilation. In order to meaningfully approach this complex topic, it is critical to contextualize both the general and sexual health of Indigenous people in Canada within the frameworks of the historical injustices they have experienced (Kirmayer, Brass, & Tait, 2000; Royal Commission on Aboriginal Peoples, 1996). Prior to European contact, Indigenous communities had strong belief systems and health frameworks that were meant to uphold the sexual health of children and adults alike (National Collaborating Centre of Aboriginal Health, 2013). Both men and women were equally respected and each had specific roles and responsibilities with regard to the maintenance of harmony in families and communities (Boyer, 2009). Traditionally, Indigenous people viewed sex as a sacred gift meant to provide pleasure and sustain life (Kliest, 2008; Newhouse, 1998). Matters of sex were openly discussed and expressed, and sexuality was accepted as a healthy and vital component of human development (Aboriginal Nurses Association, 2002; McGeough, 2008; Newhouse, 1998).  Before colonization, Indigenous children were initiated into manhood or womanhood through coming-of-age ceremonies. These ceremonies were meant to facilitate a positive sense of identity at junctures where children were believed to be at risk for biological and psychosocial stress due to natural changes in their bodies, minds, and emotions. The ceremonies were fundamental to the healthy development of sexuality  21 because they transferred values pertaining to the sacredness of sex, its connection to spirituality, and how to create meaningful relationships (Markstrom, 2008). Prescribed rules, warnings, and proverbs guided appropriate sexual behaviours and set boundaries for those behaviours. Despite heterogeneity amongst the many Indigenous cultures and communities in Canada, the over-arching general approach to sexuality was healthy (Bopp & Bopp, 1997). The strict European and Christian doctrines that deemed sex impure were a stark contrast to Indigenous traditions that celebrated it. European colonizers viewed the values of Indigenous cultures as a threat to the patriarchal and Christian society they sought to establish (Oliver et al., 2015). Indigenous scholars emphasize that dismantling Indigenous families aimed to eradicate the egalitarian and in some cases, matriarchal, nature of Indigenous societies (Barman, 1997). The residential school system severed the transmission of cultural wisdom from caregiver to child by forcibly removing tens of thousands of Indigenous children from their families and communities. The sexual abuse that was endured by almost every child in attendance attached a deep sense of confusion, pain and shame to matters of sexuality (TRC, 2015). The figures entrusted with caring for the children inflicted immense suffering and long-term damage by humiliating the children’s identities and bodies, and ultimately, their psyches (Aboriginal Healing Foundation, 2007; Fournier & Crey, 1997; Milloy, 1999). The survivors of residential schools then carried the immense burden of unresolved trauma and self-shame back home, along with the lessons they had learned about using complete adult control and abuse as a method of child rearing (Fournier & Crey, 1997, p.63). Experiencing violence in childhood is a strong risk factor for the  22 perpetration of violence during adulthood (Markowitz, 2001). Given the lack of emotional nurturing, familial kinships, and healthy role models to mirror, many residential school survivors found it incredibly difficult to build healthy relationships with their families. Unfortunately, when the survivors became parents, some began recreating the methods of child rearing that characterized their own upbringing in the residential schools. Stressful conditions at home were exacerbated by poverty, born of social marginalization and systemic racism, and the use of drugs and alcohol to cope with unresolved trauma (Bopp, Bopp, & Lane 2003, 49; Chansonneuve, 2007; Cripps et al., 2009, 484). The difficult living situations and distress experienced by residential school survivors gave rise to a new wave of familial fragmentation through the child welfare system. Social workers who deemed Indigenous homes as “unfit” for childrearing removed thousands of children from their families and placed them in foster care. This second era of child apprehension served as another means of dismantling Indigenous ways and recreating new cycles of pain (Christian, 2010; Fournier & Crey, 1997). In an examination of psychological distress and maltreatment among Cedar Project participants, young people who were apprehended as children described the immense trauma of being torn from their families and endured gross neglect and abuse at the hands of foster parents. Such experiences led them to run away from home, develop mental illness, suffer immense stress, initiate drug use, and have difficulty building and maintaining relationships (Pearce, 2014). At baseline enrolment (n=605), 65% of Cedar Project participants reported that they had been placed into foster care as children. In this cohort, being part of the child welfare system was independently associated with having  23 been sexually abused (AOR: 2.6 [95% CI: 1.7–3.8]); having a parent who attended residential school (AOR: 2.1 [95% CI:  1.4–3.2]); being diagnosed with a mental illness (AOR: 1.6 [95% CI: 1.1–2.3), and homelessness (AOR: 1.7 [95% CI: 1.2–2.4]) (Clarkson et al., 2015). The most troubling finding was the increased likelihood of having thought about (AOR: 1.8 [95% CI: 1.3–2.6) and having attempted suicide (AOR: 1.4, [95% CI: 1.0–2.1]) among participants who had been in foster care (Clarkson et al., 2015). The underlying causes that contribute to child apprehension among Indigenous families remain largely unaddressed. Consequently, Indigenous young people continue to be vastly overrepresented in the child welfare program, comprising almost half of all children in foster care under the age of 14, while constituting only 7% of the child population (Statistics Canada, 2016). Being part of the child welfare system is reported to be the most common characteristic of young Indigenous women involved in survival sex work in Canada (Sikka, 2009). Among Cedar Project participants, having been in foster care was independently associated with ever having been involved in survival sex work (AOR:1.7 [95% CI: 1.1–2.8]) and being HIV positive (AOR: 2.4 [95% CI: 1.2–5.1]) (Clarkson et al., 2015). This evidence highlights the sexual vulnerability of Indigenous people who have been taken from their families and indicates the critical need for an in-depth exploration as to how these experiences impact sexual health.  2.1.2 The impact of sexual abuse on sexual wellbeing  The most devastating corollary of colonization for the Indigenous people of Canada is the transmission of intergenerational trauma in the form of sexual abuse. The Canadian Incidence Study of Child Abuse and Neglect reports that Indigenous children are 2.7 times more likely to be sexually abused than non-Indigenous children (Public  24 Health Agency of Canada, 2010b). The researchers acknowledge that the underreporting of sexual abuse continues to be a major impediment to recognition and intervention. In the 2008 British Columbia Adolescent Health Survey of over 3,300 Indigenous young people, 27% of female participants and 11% of male participants reported having ever been sexually abused. In the 2016 survey, the overall figure dropped to 15% (Tourand et al., 2016). However, as this survey was only distributed to students who were actively attending school, it may not have captured the experiences of the most at-risk young people. Collin-Vézina, Dion, & Trocmé (2009) examined over 20 published studies and reports on the prevalence of sexual abuse within Indigenous communities in Canada from 1989-2007. The researchers conservatively estimated the overall range of sexual abuse among all Indigenous people to be 25-50%. Fear of disclosure, shame, stigma, and proximity to abusers continues to result in the underreporting of childhood sexual abuse. As such, many children are left to cope alone with its devastating long-term consequences (Collin-Vézina, Dion, & Trocmé, 2009).  Sexual abuse can grossly impede healthy sexual development, especially during childhood. Very few studies have examined the mental and emotional sequelae associated with sexual abuse exclusively among Indigenous people who use drugs in Canada. To understand the psychological impacts of sexual abuse on lifetime sexual vulnerability, we must turn to literature that is informed by the non-Indigenous population. It is essential to distinguish between cause and effect when discussing sexual abuse in childhood and its resultant sexual health outcomes. Sexual abuse in and of itself does not necessarily cause such outcomes, but rather, increases the likelihood that victims will find themselves in situations that increase vulnerability to them (Stoltz et al., 2007). For example, a child  25 who has been sexually abused may not be able to focus in school and may withdraw from social engagements, peer networks, and community involvement. Such losses can negatively impact their self-sufficiency, confidence, and ability to succeed in various lifetime endeavours. Many victims are consequently at risk for experiencing poverty, running away from home, and becoming dependent on other exploiters or abusive partners to survive (Grauerholz, 2000; Johnson et al., 2006; Stoltz et al., 2007).  Coping strategies are also important mediators in the pathways of childhood sexual abuse and poor sexual outcomes. Sex itself, even when consensual, can trigger flashbacks, fear, and a sense of helplessness (Briere & Elliot, 1994; Harris, 1999). Survivors may suppress negative feelings through emotional avoidance, which can include self-medication, dissociation, and detachment. Over time, chronic emotional avoidance can inhibit the processing of information during sexual encounters and lead to a tendency to ignore/minimize danger cues, increasing susceptibility to re-victimization (Polusny & Follette, 1995). Further, the depression and grief that accompanies abuse can instill a sense of futility in living and a lack of self-protection. This hopelessness can lead sexual abuse survivors to seek the immediate gratification of risky sex with multiple short-term partners and be unconcerned about taking sexual precautions (Johnson et al., 2006; Slonim-Nevo & Mukuka, 2007).  The ability to regulate the dynamics of sexual encounters, such as voicing preferences on contraceptive use, or refusing to engage in any act that is uncomfortable necessitates self-esteem and assertiveness. Sexual abuse can inhibit the development of such protective qualities, and many survivors lack the ability to control their sexual environment, even when sex is consensual (Brown et al., 2014; Prentice, 2005; Ship &  26 Norton, 2001; Simoni, Seghal, & Walters, 2004). The use of drugs and alcohol as a means of numbing the immense pain of sexual maltreatment further increases these vulnerabilities (Walters & Simoni, 2002). This can be explained through heightened risk of being preyed upon when high/intoxicated, not being in control of the sexual encounter when under the influence, and becoming involved in survival sex work to support substance dependence (Barlow, 2003; Bell & Britton, 2014; Gesink et al., 2016; Schneider et al., 2012).  One of the most troubling findings from the Cedar Project is the high proportion of participants who have experienced childhood sexual abuse (69% of women, 31% of men), and its significant association with having ever attempted suicide (AOR: 2.02 [95% CI:1.36–3.01]) (For the Cedar Project Partnership, 2008). In the Cedar Project, childhood sexual abuse is independently associated with inconsistent condom use (AOR: 1.80 [95% CI: 1.01-3.20] (Chavoshi et al., 2012), homelessness (AOR: 2.08 [95% CI: 1.36-3.12], involvement in survival sex work (AOR:1.92 [95% CI: 1.25–2.96], and HIV positivity (AOR: 2.09 [95% CI (1.00–4.34]) (For the Cedar Project Partnership, 2008). The BC Adolescent Health Survey reported that young men who were sexually abused were 4.5 [95% CI: 1.69-12.09] times more likely to use condoms inconsistently (Devries, et al., 2009b). The Ontario Federation of Indian Friendship Centres surveyed 255 Indigenous young people in Ontario and found those who had endured childhood sexual abuse were more likely to have multiple sex partners and become pregnant (Anderson, 2002). Devries et al. (2009a) investigated the determinants of STI acquisition and pregnancy among the 445 young women and 360 young men who identified as Indigenous and reported ever having sex in the 2003 BC Adolescent Health Survey. Among men,  27 experiencing sexual abuse was significantly associated with causing a pregnancy (AOR: 4.30 [95% CI: 1.64-11.25]) and being diagnosed with an STI (AOR: 5.58 [95% CI:1.61-19.37]). For young women, a history of sexual abuse was independently associated with ever having become pregnant (AOR: 10.37 [95% CI: 4.04-26.60]). 2.1.3 The ongoing impacts of colonization on the sexual health of Indigenous women  Prior to European contact, Indigenous women often held positions of high social power, and rightfully exercised autonomy over their bodies and sexuality. Revered as the givers of life to subsequent generations and transmitters of knowledge, Indigenous women were perceived as a threat to the patriarchal agenda of the colonizers. The degradation of female sexuality, attempted eradication of egalitarian values, and objectification of Indigenous women critically wounded their safety, social status, and overall health (Oliver et al., 2015; Robinson, 2009). As a result of the complex intersections of race, gender, and social class, Indigenous women today experience higher rates of poverty, inadequate food security, and extreme violence and abuse (Callaghan et al., 2006; CBC, 2015b; Macdonald, 2005; van der Woerd et al., 2005; Milloy, 1999; Stout, Kipling & Stout, 2001; Yee, Apale & Deleary, 2011; Young & Katz, 1998). In 2010, 582 cases of missing and murdered Indigenous women in Canada were documented. More than half were under the age of 31 and 88% were mothers, and only a few cases have been solved (The Native Women’s Association of Canada, 2010). By 2014, the Royal Canadian Mounted Police reported they were investigating over 1,200 cases of missing and murdered Indigenous women (RCMP, 2014). The Native Women’s Association of Canada attribute this crisis to “the ongoing effects of Colonization in Canada (that) have led to the dehumanization of Native women and girls” (Gahagan,  28 2013; p. 19). The culmination of such disparities significantly impacts the sexual wellbeing of Indigenous women, who experience disproportionate rates of unplanned pregnancies, sexual violence, maternal mortality, and STIs (Oliver et al., 2015; Robinson, 2009; Stout, Kipling & Stout, 2001).  For Indigenous women, sexual abuse has been linked to HIV infection, self-medication, survival sex work, powerlessness in relationships, and a reduced ability to negotiate contraceptive use (Prentice, 2004; Ship & Norton, 2001; Simoni, Seghal & Walters, 2004; Sikka, 2009; Spittal et al., 2007). Indigenous women are more likely to suffer from the long-term mental health effects of childhood sexual abuse than non-Indigenous women. In Barker-Collo’s 1999 study of 138 female survivors of childhood sexual abuse, Indigenous participants (n=60) were more likely to report trauma symptomology such as sleep disturbance, somatic symptoms, and sexual difficulties. Gesink et al. (2016) interviewed 25 Cree women in Alberta in an investigation of STI vulnerability. They found that both substance dependence and abuse in relationships greatly impacted women’s sexual health risks. The authors explained how sexual abuse survivors turn to “healing” and “harming” medicines to overcome their suffering. “Harming” medicines included drugs, alcohol, and self-harming, which directly increased risk of contracting STIs. “Healing” medicines including engaging in traditional practices and ceremonies, which mediated against STIs.  The sexual vulnerability of Indigenous young women is compounded by their overrepresentation among women engaged in survival sex work (Chettier et al., 2010; Native Women’s Association of Canada, 2008; Sikka, 2009; Seshia, 2005). Young Indigenous women involved in survival sex work face inadequate access to health  29 resources (Ontario Federation of Indian Friendship Centres, 2004) and are more likely to test positive for STIs (Shannon et al., 2007). In a study among 198 women who trade sex for survival in Vancouver, Indigenous participants were significantly more likely than non-Indigenous participants to avoid accessing health services and clean injection sites due to a fear of violence and policing (Shannon et al., 2008), with clear implications for treatment, prevention, and care.  As previously mentioned, precise estimates of STI prevalence and incidence among Indigenous people are not readily available in Canada. This is due to inconsistencies in ethnicity reporting and inadequate STI screening, particularly in rural and remote areas where many Indigenous communities are located. From the data that is available, Indigenous women are disproportionately represented (BCCDC, 2013; Healey et al., 2001; Vasilevska et al., 2012). Indigenous girls are more likely to have earlier sexual debuts than non-Indigenous girls (Larkin et al., 2007). This is concerning given that the cervixes of adolescent girls are not fully developed, increasing their susceptibility to STIs (Young et al., 1997). Indigenous women are also less likely to be screened for STIs, and more likely to experience the negative consequences of untreated infections, such as infertility, pelvic inflammatory disease, and ectopic pregnancies (Calzavara et al., 1998).  The historical and social adversities that Indigenous women experience not only increase vulnerability to STI acquisition independently, but many are experienced concurrently, resulting in a multifold cumulative risk for negative sexual health outcomes. Young women who use drugs are particularly vulnerable. Yet, no studies have independently examined the determinants of sexual health for Indigenous women who  30 use drugs in Canada. Research is urgently needed to identify not only the risk factors associated with increased sexual health risks, but also the protective mechanisms that support the sexual wellbeing of Indigenous women.  2.1.4 Social marginalization and accessing resources, treatment, and care Indigenous people do not have equitable access to relevant sexual health resources that mitigate negative sexual health outcomes. This reality is a product of cultural, geographic, socioeconomic, and historical factors (Browne, 2011; First Nations Health Authority, 2013; Tang & Browne, 2008; Waldram et al., 1997). Wynne and Currie (2011, p. 115-116) argue that the underlying theme of such reduced access and uptake is social exclusion (or social marginalization), which they define as “the structures and processes that limit the full participation of certain groups or individuals in society due to inequalities in access to social, economic, political, and cultural resources”. Social exclusion manifests in the forms of racism, poverty, and residential segregation, all of which can increase vulnerability to poor health outcomes. Consequently, socioeconomically disadvantaged groups face heightened risk for STI acquisition (Wynne & Currie, 2011). This is concerning, as almost half of all First Nations children in Canada are living below the poverty line in marginalized neighbourhoods. Indigenous children are thus facing increased exposure to a concentration of social risk factors that reduce sexual wellbeing. These include high rates of violence, addiction, survival sex work, and a lack of resources (McDonald & Wilson, 2013).  An important deterrent to healthcare access and uptake is systemic racism (Clark et al., 2013). Racism not only influences how healthcare providers treat patients belonging to a group perceived as unhealthy, which impacts how members of that group  31 internalize such perceptions (Williams & Mohammed, 2009). The overrepresentation of Indigenous people who have chronic healthcare needs, are economically disadvantaged, and/or substance dependent has been found to impact how healthcare providers interact with Indigenous patients in general (Tang & Brown, 2008). Tang and Brown’s 2008 ethnographic study explored how ethnicity functioned as a barrier to the provision and uptake of equitable healthcare services among Indigenous people in Canada. While most healthcare providers believe they are dispensing indiscriminate care, many Indigenous patients report being racially typecast. A person who expects to be discriminated against by healthcare providers may refrain from seeking care unless it is absolutely necessary, or not seek care at all (Health Council of Canada, 2012). As STIs are often viewed as a product of personal decisions, the social and historical conditions that increase any particular group’s vulnerability to STIs are often overlooked, which impacts both the provision of quality care and its frequency of uptake (Wynne & Currie, 2011).   Sexual healthcare resources are strikingly deficient in Indigenous communities located in rural or remote areas (Jackson & Reimer, 2008). Goldenberg et al. (2008) interviewed 25 young men and women in Northeastern BC, 10 of whom were Indigenous. The researchers identified five main barriers to STI testing, which included: limited opportunities to access STI testing; the geographic inaccessibility of clinics; local social norms/stigma; lack of information regarding STIs and testing options; and negative interactions with service providers. The latter included the inability to establish rapport, not receiving adequate lay information, discrimination, and being denied testing.  Goldenberg’s (2008) study participants stated that a lack of anonymity was a deterrent to seeking STI care in many small towns. Such conditions were accompanied by  32 prevalent hypermasculine mentalities that deemed STI testing to portray weakness in men. Women also reported being subjected to gender stereotypes that prevented them from seeking STI screening. Disclosing sexual behaviours was associated with fear of judgment and was felt to compromise their reputations. Rusch et al. (2008a) assessed stigma attached to STIs among 126 women living in Vancouver’s Downtown Eastside (the DTES). In their study, women of Indigenous ethnicity (40% of study participants) had higher scores for both social (views about women with STIs) and internal stigma (shame, embarrassment, etc. around having an STI). Internal stigma was present for Indigenous women even after adjustment for age, education, injection drug use, and survival sex work. The authors attributed their findings to the conflicting ideals of female sexuality between traditional Indigenous and western cultures. Indigenous women who had ever received STI testing or treatment had significantly lower social and internal stigma scores. The authors suggest that having received STI care and treatment may have mitigated some previously-held stigma (Rusch et al., 2008b).  2.2 Vulnerability to sexually transmitted infections among Indigenous people in Canada 2.2.1 Condom use among Indigenous people  The association between increased vulnerability to STIs and inconsistent condom use is clear and critical to the investigation of sexual health determinants. Statistics Canada survey data demonstrate that the odds of not using condoms among Indigenous men are twice that of non-Indigenous men (Rotermann, 2005). The First Nations Regional Health Survey 2008-2010 reported that only one-fifth of 11,043 participants reported always using a condom. In this study, participants who were substance  33 dependent were significantly less likely to report consistent condom use (First Nations Information Governance Centre, 2012). Condom use consistency for both the general and Indigenous population is largely dependent on type of sexual partner. Generally, condoms are infrequently used with regular partners, and varyingly with casual partners (Chavoshi et al., 2012; Devries et al., 2011; Hogg et al., 2005). In the Cedar Project 59% of women, and 46% of men reported inconsistent condom use, which was defined as “not always using condoms during vaginal and/or anal sex” (Chavoshi et al., 2012). The disproportionate representation of Indigenous people who have contracted STIs speaks to high rates of inconsistent condom use. A better understanding of the various determinants of condom use among Indigenous people is therefore required. The injustices of colonialism have resulted in an overrepresentation of Indigenous people involved in survival sex work (Chettier et al., 2010; Hunt, 2013). With few rights to protection and reduced social empowerment, people involved in survival sex work become especially vulnerable to violence, which often serves as a barrier to condom negotiation (Shannon & Csete, 2010). According to the Vancouver Injection Drug Users Study (VIDUS), 82% of Indigenous women who engaged in survival sex reported consistent condom use with their clients (Hogg et al., 2005). Among Cedar Project participants involved in survival sex work, consistent condom use with clients was reported by 89% of women and 63% of men. Only a minimal number of participants reported ever having accepted increased payment to not use a condom (16% of women, 0% of men) (Chavoshi et al., 2013). However, this must be interpreted with caution as results are based on self-reported data, which may be influenced by social desirability bias. Survival sex work is also strongly associated with drug use, particularly crack,  34 which is in turn associated with unprotected sex (Chavoshi et al., 2013; Chettier et al., 2010; Duff et al., 2013; Kuyper et al., 2005; Mehrabadi et al., 2008a). Therefore, even if the intention to use condoms is consistently present among people who engage in survival sex work, it may not readily be actualized while under the influence of drugs.  The severance of traditional wisdom regarding the sanctity and normalcy of sex, and intergenerational trauma have embedded the topic of sex among many Indigenous communities in silence (Yee, 2010). Consequently, bringing the topic of condom use to the forefront with communities that rarely discuss sex is challenging. Myers et al. (1999) investigated whether a relationship between cultural variables and risky sexual behaviors existed in a study among 556 Indigenous people in Ontario. Consistent condom use was reported by only 8% of participants. The authors found learning about sex through Indigenous traditions to be associated with reduced sexual activity (AOR:0.56 [95% CI: 0.33-0.95]). These findings illustrated the protective effect of cultural connectivity on sexual activity among young people. The same study found that participants who identified “family” as their source of sexual education were more likely to have unprotected sex (AOR: 2.50 [95% CI: 1.48-4.30]). Conversely, having received sexual education through health services was associated with a reduced likelihood of having unprotected sex (AOR: 0.51 [95% CI: 0.32-0.80]). The authors attributed these findings to the difficulty of addressing sexual matters in Indigenous homes that lack access to traditional teachings for sexual education. From the same cohort, Calzavara et al. (1998) reported that condom use consistency was positively associated with being male, not having a regular partner, having multiple partners, being concerned about pregnancy, having knowledge about HIV/AIDS, and not being embarrassed to purchase/obtain  35 condoms. Condoms were more commonly viewed as barriers to pregnancy than as barriers to STIs, heightening the risk for contracting STIs among people who used other methods of contraception (Calzavara et al., 1998).   In the most recent BC Adolescent Health Survey, 27% of Indigenous young men and 36% of Indigenous young women reported inconsistent condom use (Tourand et al., 2016). In Anderson’s (2002) study, more than half the youth participants reported inconsistent condom use. The First Nations Regional Health Survey (2008-2010) reported that 28% of its 4,837 persons cohort (aged 12-17) was sexually active. Of this group, 79% reported using condoms, but 41% used them inconsistently. Among sexually active young people, only 9.6% had ever been tested for an STI (First Nations Information Governance Centre, 2012). The Nunavut Sexual Health Survey of 102 Inuit high school and college students reported 33% of young men and 42% of women use condoms inconsistently, only 20% of whom had been tested for an STI (Cole, 2004). Shercliffe et al.’s (2007) survey of 68 young Indigenous women in Regina reported that only half the participants had used condoms in their last sexual encounter. Despite their having knowledge about sexual health, sexual health awareness did not result in increased condom use. Instead, the authors found that having assertive communication skills determined their use (Shercliffe et al., 2007).  The reviewed studies did not address any historical or social factors that impact safe sex in their cohorts and excluded any young people who were not in school. Further, they did not examine the complex relationships between trauma, self-medication, and sexual health. Consequently, they may have underestimated risk due to sampling bias by missing critical information from the most vulnerable young people in society (Thomas,  36 2016). To appropriately design and develop sexual health programs that promote sexual safety among Indigenous young people who face adversities, the various factors that impact sexual education, attitudes, and behaviours need to be better understood.  2.2.2 Sexual health education, perceptions, and attitudes among Indigenous young people  The difficulty of discussing sex in many Indigenous communities obstructs the transmission of sexual health knowledge from adults to children. Indigenous researchers have greatly criticized the inadequacies of current sexual health education and programming. They have drawn attention to shortages of meaningful sexual health resources for Indigenous young people (Banister & Begoray, 2011; Clark & Hunt, 2011; Yee, 2010). While a critical lack of evidence pertaining to attitudes and knowledge about sexual health among Indigenous young people exists, a few researchers have addressed this important topic. For Indigenous young men and women, strong cultural, family, community, and school connectedness has been found to instill self-care, which can in turn result in positive sexual health outcomes (Devries et al., 2009b). Indigenous young men with unstable family dynamics have reported engaging in risky behaviours by frequently migrating to larger cities to use alcohol and have sex (Devries et al., 2011). In a cross-sectional analysis of the BC Adolescent Health Survey, young women who reported involvement in their community or with strong connections to school were 26% less likely to have sex (Devries et al., 2009b). Devries et al. (2009b) reported that strong family connections decreased inconsistent condom use for both young girls (AOR: 0.43 [95% CI: 0.19-0.99]) and boys (AOR: 0.48 [95% CI: 0.26-0.91]). Consequently, Indigenous young men and women with strong connectedness to family and school were  37 less likely to report ever having an STI or having become pregnant (Devries et al., 2009a).  Larkin et al. (2007) developed a focus group study to assess understandings of HIV/AIDS among 48 young Indigenous participants aged 14-29 in Ontario. Participants struggling with poverty highlighted prioritizing the purchase of basic essentials such as food over contraception. This important finding speaks to a critical structural barrier to sexual safety that stems from ongoing marginalization. In Larkin’s study, young people also discussed their strong community ties and the support they drew from it. Given that their communities lacked readily available sexual health resources, the researchers singled out strong community identification as an important factor for mitigating HIV/AIDS risks. In the most recent BC Adolescent Health Survey, Indigenous young people in BC who reported strong connectedness to school and family demonstrated a delayed sexual debut (Tourand et al., 2016). Unfortunately, any protective effect of school connectedness will not benefit Indigenous young people who are not attending school. This is particularly concerning given that ongoing social exclusion, child apprehension, and marginalization continue to interfere with regular attendance and graduating high school among Indigenous young people in Canada (Statistics Canada, 2011a; van der Woerd et al., 2005). Sociocultural subtleties of sexual encounters and gender norms can additionally impact sexual behaviours. In Larkin et al.’s study, young Indigenous women were vocal about a prevalent mentality that labeled girls who purchase/carry condoms as promiscuous. Devries and Free (2010) interviewed 30 young Indigenous men and women in downtown Vancouver on gendered perspectives on sexual roles. Men were considered  38 to be the active pursuers of sex and young women were expected to resist their advances, but were also regarded as responsible for allowing sex to happen. Young girls who “gave in” to sex were viewed as trying to secure love or companionship if they were in a relationship, but were deemed “loose” if they were not. The respective active versus passive prescribed roles for men and women were apparent and influenced how they interpreted each other’s behaviours.  In focus groups conducted with 35 young Mi’kmaq women and men in Nova Scotia, participants reported experiencing immense stress due to pressures to have sex while feeling the burden of sexual health concerns (McIntyre et al., 2001). The women perceived young men to not share such stresses, but acknowledged that this could be because men internalize their emotions. However, the 14 men who participated in this study listed relationships with girlfriends as the main stressor in their lives, followed by substance use, and financial troubles. These young men agreed that young women face increased pressure to have sex and risk of sexual violence and unplanned pregnancies. At the same time, they perceived young women who had sex to be promiscuous (McIntyre et al., 2001). Masculine and feminine stereotypes can pressure young men and women to behave in an expected manner. However, Devries and Free (2010) demonstrated that sexual behaviours among Indigenous young people can contradict such hegemonic ideals. Women reported acting as the pursuers of sex while young men shared that they were coerced into having sex and/or to refrain from using protection. It is clear that young Indigenous men’s and women’s sexual behaviours are both within and outside of western masculine and feminine norms, which points to a need for a more in-depth investigation  39 of the factors shaping these understandings and the associated behaviours.  2.2.3 The epidemiology of HIV/AIDS, HSV-2 and syphilis among Indigenous people in Canada A disproportionate burden of HIV/AIDS in Canada is borne by Indigenous people. HIV rates in the general population are low, but are reported to be as high as 20 times the national average (63.6/100,000) among people living on-reserve (CBC, 2015a). In 1998, only 2% of people with AIDS were Indigenous people. By 2006, this figure had increased over ten-fold (Public Health Agency of Canada, 2015). While Indigenous people only comprised slightly less than 4% of the general population in 2011, they constituted almost 9% of all prevalent HIV infections. Indigenous people were also 3.5 times more likely to be newly infected with HIV than non-Indigenous people (Public Health Agency of Canada, 2015).  The proportion of HIV incidence among young people, women, and people who use intravenous drugs is higher within the Indigenous population when compared to the general population. Between 1998 and 2012, persons aged 15-29 years comprised 32% of positive HIV tests among Indigenous people. In the general population, only 22% of positive cases belonged to that age category. In the 14-year span between 1998 and 2012, intravenous drug use was the main source of infection among Indigenous people (59% vs. 18% in the general population), followed by heterosexual transmission (30% vs. 32%), and transmission among men who have sex with men (7% vs. 46%) (Public Health Agency of Canada, 2015).  In 2012, BC reported its lowest provincial HIV infection rate since 2003 (5.2/100,000 people). Unfortunately, Indigenous people were still vastly overrepresented among new cases, with 29 new infections recorded (21.5/100,000 people). Although  40 Indigenous people represented only 5% of the provincial population, on average, they comprised 15% of new HIV cases between 2003 and 2012 (BCCDC, 2013). A ten-year analysis of all syphilis cases reported by the British Columbia Sexually Transmitted Disease Surveillance Database revealed that Indigenous people comprised 17% of all (n=1,473) cases in BC from 1995 to 2005 and were at higher risk for reinfection (Hazard Ratio (HR): 2.4 [95% CI: 1.3–4.4]) (Oglivie et al., 2009). The Annual Summary of Reportable Diseases in BC identified that First Nations people accounted for 9.1% (n=277) of the province’s newly reported syphilis cases between 2004-2013, despite comprising only 5% of the population. However, this estimate did not include data on Inuit, Métis people, or people living on-reserve. As a result, an accurate estimation of the prevalence of syphilis among Indigenous people in BC is not available.  While the rate of new syphilis cases among Indigenous people in BC declined between 2005 and 2010, it has started to increase once again (BCCDC, 2013). Over the past few years, Canada’s western provinces have reported a surge in syphilis outbreaks. A disproportionate portion of these newly infected cases are occurring among Indigenous people (CBC, 2010; CBC, 2015a; Government of Alberta, 2010). Many are in remote areas with inadequate medical care, STI screening, and post-natal care. Despite such reports, the associated ramifications and risk factors are not well-established for Indigenous communities. Moreover, the prevalence of and risk factors for syphilis positivity among Indigenous people who use drugs has never been examined. Genital herpes is the second most prevalent sexually transmitted viral infection in Canada. While HSV-1 can cause genital ulcerations too, genital herpes is largely attributed to the HSV-2 strain (BCCDC, 2007; WHO, 2016). A screening of 3,247 men  41 and women between 2009 and 2011 estimated the prevalence of HSV-2 among Canadians aged 14-59 to be 13.6% (2.9 million people). Among this group, only 6% were aware of their infection status. Data on Indigenous identity were not available, and participants living on-reserve were excluded (Statistics Canada, 2011b).  In BC, over 2,500 positive cases of HSV-2 were reported in 2006 by the BCCDC alone (Li et al., 2008). While the increased risk of HSV-2 among Indigenous people has been monitored and documented by our Australian colleagues (Brazzale et al., 2010; Butler et al., 2000; Communicable Disease Control Directorate Department of Health, 2010), there are very few estimates of HSV-2 prevalence among Indigenous people in Canada. The only available data is from Singh et al. (2005). The researchers examined HSV-2 positivity among 7,266 patients attending two STI clinics in Alberta from 1994 to 1995, 6% of whom were Indigenous. They reported a 19% overall prevalence, and found that Indigenous patients were 2.6 [95% CI: 2.0-3.4] times more likely to test positive.  2.2.4 The epidemiology of HIV/AIDS, HSV-2 and syphilis among Indigenous women in Canada In Canada’s general population, HIV/AIDS and syphilis rates are higher among men, but national surveillance data demonstrate that Indigenous women are almost equally at risk. In 1995, Indigenous women represented only 12% of all Indigenous people who were HIV positive; by 2012, this figure had more than quadrupled (Public Health Agency of Canada, 2015). Between 1998-2012, while men comprised 80% of HIV cases in the non-Indigenous population, Indigenous women were almost equally represented as men in the Indigenous population (47% vs. 53%). Indigenous women were also significantly overrepresented among all women, comprising 42% of all HIV cases. The primary mode of transmission for Indigenous women was injection drug use (64%  42 vs. 24% in non-Indigenous women). Heterosexual transmission still accounted for 34.8% of infections among Indigenous women (compared to only 21.5% of Indigenous men) (Public Health Agency of Canada, 2015).  The BCCDC (2013) reported Indigenous women to be overrepresented among women with HIV (37.9% of all cases among women) in British Columbia, with the highest number occurring in the 25-29 year age category (53.6/100,000 people). Indigenous women comprised 36.7% of new HIV infections among all Indigenous people in the province, while non-Indigenous women accounted for only 7.6 % of new infections in the non-Indigenous population of BC.  An overrepresentation of Indigenous women among syphilis cases has also been reported. Indigenous men accounted for only 4.3% of all syphilis infections among all men in BC. Indigenous women comprised, on average, 27% (n=118) of all cases among women from 2004-2013, despite accounting for only 5% of women in the province. During the same time period, non-Indigenous women comprised 11% of all syphilis cases in the non-Indigenous population, while Indigenous women accounted for 43% of all syphilis cases among the Indigenous population (BCCDC, 2013).  The rate of HSV-2 among Indigenous women in Canada is unknown. Kropp et al. (2006) investigated rates of neonatal herpetic infections by actively soliciting reports from all pediatricians in Canada over a three-year period (2000-2003). The authors demonstrated that Indigenous women represented 10.5% of study cases, despite only comprising 3.4% of the birthing population. In the general population, women are reported to be at higher risk for HSV-2 infection than men. Of the 2,500 cases that were reported by the BCCDC in 2006, women were 2.4 times more likely to be infected  43 (84/100,000 cases among women vs. 35/100,000 in men) (Li et al., 2008). The national screening of 3,247 Canadians aged 14-59 from 2009-2011 reported infection rates among women to be 1.5 times that of men (Statistics Canada, 2011b).  2.3 Drug use and sexual health risks  2.3.1 The association between substance dependence and STI risk among Indigenous people Indigenous scholars emphasize that self-medication is a coping mechanism for people who are suffering from unresolved trauma and psychological distress (Walters & Simoni, 2002). For Indigenous people who use drugs, having experienced lifetime trauma has been found to independently predict inconsistent condom use (Chavoshi et al., 2012). A five-year longitudinal analysis of inconsistent condom use among Cedar Project participants found a significant association between unsafe sex and daily crack smoking among women (AOR: 1.63 [95% CI: 1.02-2.61]), men (AOR: 1.58 [95% CI: 1.05-2.38]), and participants who use injection drugs (AOR: 1.59 [95% CI: 1.04-2.43]) (Chavoshi et al., 2013). Researchers have demonstrated a strong correlation between sexual activity and frequent alcohol use among sexually active Indigenous young people (Devries, Free, & Jategaonker, 2007; First Nations Information Governance Committee, 2012; Kotchick et al., 2002). Anderson’s 2002 study found 17% of sexually active participants to cite being “drunk or high” as the reason for not only having sex, but for young women becoming pregnant.  In a cross-sectional analysis of the BC Adolescent Health Survey of students grade 7 to 12, 26% of young men and 22% of young women stated that they were under the influence of substances during their last sexual encounter (Tsuruda et al., 2013). In  44 the most recent BC Adolescent Health Survey, one-quarter of Indigenous young people reported having used drugs and/or alcohol during their last sexual encounter. Ten percent reported having had nonconsensual sex while under the influence (Tourand et al., 2016). In the First Nations Regional Health Survey 2008-2010, of the 631 participants who reported not using condoms, 16.5% attributed the cause to drinking and/or having use drugs (First Nations Information Governance Centre, 2012). In the 2003 BC Adolescent Health Survey, young Indigenous men who used drugs were significantly more likely to have had an STI diagnosis (AOR: 4.60 [95% CI: 1.11-19.14]). For the young Indigenous women who participated in the survey, substance use was an independent risk factor for pregnancy (AOR: 3.36 [95% CI: 1.25-9.08]) and an STI diagnosis (AOR: 5.27 [95% CI: 1.50-18.42]) (Devries et al. (2009a).  2.3.2 Ulcerative STIs among people who use drugs in the general population  As previously mentioned, no known studies to date have examined the prevalence of or risk factors for HSV-2 or syphilis infection among Indigenous people who use drugs. To understand vulnerability to these ulcerative STIs due to drug use, we must rely on literature from the general population of people who use drugs. People who use drugs frequently do so during sexual encounters, which reduces the likelihood of condom use (Devries et al., 2008; Marshall et al., 2009; Rawson et al., 2002). They are also more likely to have sex with a partner who uses injection drugs, exchange sex for drugs or money, and have multiple sex partners. Consequently, people who use drugs face increased risk for STI acquisition when compared to people who do not (Booth et al., 2000; Booth et al., 2007; Irwin et al., 1993). In the United States, HSV-2 infection rates among people who use drugs have  45 been found to be significantly higher than that of the general population (Des Jarlais et al., 2010; Xu et al., 2006). As HSV-2 is transmitted by sexual activity rather than drug use, it is considered an effective biomarker of sexual risk for people who use drugs (Des Jarlais et al., 2011). Among this already vulnerable group, the highest rates of HSV-2 infection are reported among men who have sex with men and women who engage in survival sex work (Des Jarlais et al., 2011; Plitt et al., 2005).  In a study of 1,418 people who use non-injection drugs in New York City, the prevalence of HSV-2 was 53% among men and 85% among women. In this study, a significant association was found between HSV-2 and HIV (AOR: 3.2 [95% CI: 2.3-4.5]) (Des Jarlais et al., 2010). The authors attributed this association to non-injection crack use and risky sexual behavior. They found that women who were HSV-2 positive were significantly younger than men who were HSV-2 positive. In Des Jarlais et al.’s 2011 study among 337 people who used injection drugs, HSV-2 prevalence was 39%. The authors reported an even higher association between HSV-2 and HIV (AOR: 7.9 [95% CI: 2.9-21.4]). These data yield a population-attributable risk percent (PAR%) of 71% for HSV-2 in the etiology of HIV infection.  Plitt et al. (2005) recruited people 15-30 years of age who used drugs in Maryland. HSV-2 positivity was found to be 59% among women and 22% among men. Predictors for HSV-2 positivity among women included being involved in survival sex work (AOR: 3.2 [95% CI: 1.2-8.6]) and daily heroin use (AOR: 3.6 [95% CI: 1.6-7.7]). Among men, HIV positivity (AOR: 11.1 [95% CI: 1.8-67.5]) and ever having been incarcerated (AOR: 2.7 [95% CI: 1.1-6.6]) were associated with HSV-2 positivity. In the same study, syphilis positivity was 4.3% among women, and 0.3% among men. The low  46 rates of self-reported STIs were attributed to low healthcare utilization, especially in cases of asymptomatic infections.  Hwang et al. (2000) examined STIs among 407 Texas-based people who used drugs. HSV-2 and syphilis prevalence were 44% and 3.4%, respectively. For both STIs, prevalence was significantly higher among women than men (75% vs. 33% for HSV-2; 6% vs. 3% for syphilis). Women who tested seropositive for syphilis were more likely to be involved in survival sex work (8% vs. 3%). HSV-2 positivity was significantly higher among individuals who used crack cocaine (53% vs. 28%) and who were involved in survival sex work (74% vs. 41%). In a study of people who used crack in Texas, syphilis and HSV-2 prevalence was found to be 13% and 61%, respectively (Ross et al., 1999). Ross et al. (2002) later compared participants who preferred crack cocaine to other drugs. The authors found an increased likelihood of testing positive for both syphilis (9% vs. 3%, p<0.01) and HSV-2 (61% vs. 36%, p<0.01). Lopez-Zetina et al. (2000) enrolled 513 people in Los Angeles who used injection drugs. In this cohort, syphilis incidence was 26.0 per 1,000 person years, with women being at higher risk (Rate Ratio (RR): 2.70 [95% CI: 1.60, 4.55]). After controlling for age, sex, ethnicity, and survival sex work, recent transition to injection drug use was associated with syphilis infection (RR: 4.6 [95% CI: 1.1-18.8]).  2.4 Ulcerative sexually transmitted infections and HIV seroconversion 2.4.1 The association between HSV-2 and HIV seroconversion Heightened vulnerability to ulcerative STIs is especially concerning as genital ulcerative diseases are associated with increased risk for HIV seroconversion (Brown et al., 2007; Chen et al., 2000; Celum et al., 2008; Grey et al., 2009; Hayes et al., 1995;  47 Kaul et al., 2004; Orroth et al., 2006; Serwadda et al., 2003; Sutcliffe et al., 2002). As no Canadian studies and no studies among Indigenous populations have examined the relationship between ulcerative STIs and HIV, we look to international studies among the general population to understand this association.   Kaul et al. (2004) evaluated the STI/HIV pathway among 466 Kenyan women engaged in survival sex work. The authors demonstrated the most pronounced association to be between HSV-2 and HIV (RR: 6.3 [95% CI: 1.5-27.1]). Sutcliffe et al. (2002) conducted a nested case control study within a prospective study of HIV seroconverters among sugar estate workers in Malawi. They reported the odds of HIV serocoversion due to HSV-2 to be 6.34 [95% CI: 1.24-32.45]. The researchers calculated the adjusted PAR% to be 69.3% [95% CI: 48.2%-81.8%]. Renzi et al. (2004) interviewed HIV seronegative men who have sex with men in the USA every six months over an 18-month period. Their case control study matched HIV seroconverters (n=116) to men who remained seronegative (n=342) based on sexual risk factors. HSV-2 seropostivity was associated with 1.8 times [95% CI: 1.1-2.9] the risk for HIV seroconversion in multivariate modeling, even after adjusting for injection drug use.  Two systematic reviews of longitudinal cohort studies examined scenarios wherein HSV-2 infection preceded HIV and then adjusted for sexual behavior. The authors demonstrated the HSV-2 related risk for acquiring HIV to be 3.1 [95% CI: 1.7-5.6] among women, 2.7 [95% CI: 1.9-3.9] among heterosexual men, and 1.8 [95% CI: 1.2-2.4] among men who have sex with men (Freeman et al., 2002; Wald et al., 2006). Chen et al. (2007b) conducted a systematic review of 17,000 HIV cases and 73,000 controls from 1986-2006. The authors used a random effects model, stratified by age,  48 time, background HIV prevalence, and other variables to evaluate the association between HSV-2 infection and HIV. The researchers reported the odds of HIV seroconversion due to HSV-2 to be 4.62 [95% CI: 2.85-7.47] among women and 6.97 [95% CI: 4.68-10.38] among men. There are several biological mechanisms that facilitate the increased opportunity for HIV seroconversion due to HSV-2 infectivity. Genital ulceration caused by untreated STIs provides a portal for HIV entry through mucosal disruption (Centers for Disease Control and Prevention, 1998); the presence of untreated STIs in the human body can lead to immunosuppression and increase susceptibility to acquiring new infections; and recurrent infections disrupt epithelial cells in the ulcerated region, recruiting activated CD4 cells that are targeted by HIV (Celum, 2004). Brown et al. (2007) monitored HIV seroconversion among 8,346 women in Uganda and Zimbabwe. In their cohort, 211 participants seroconverted to HIV. The researchers calculated the PAR% and estimated that 42%-65% of new HIV infections could have be avoided if participants had been HSV-2 negative.  2.4.2 The association between syphilis and HIV seroconversion As with HSV-2, any understanding of the increased risk for HIV seroconversion due to syphilis infection is reliant on data from other countries. Taha et al. (1998) examined the association of various STIs with HIV seroconversion risk among 1,196 women attending a neonatal clinic in Malawi. The researchers reported the odds of HIV seroconversion due to syphilis to be 3.65 [95% CI: 1.22-10.93].  Chesson and Pinkerton (2000) used annual incidence rates of gonorrhea, chlamydia, herpes, and syphilis to estimate the probability that an STI would facilitate  49 HIV seroconversion. Among the examined STIs, the “expected number of STI attributable HIV infections per STI” was highest for syphilis (0.024 new HIV cases per syphilis case). Chesson (1999) created two models to examine the association: one based on the per partnership probability of HIV transmission in the presence of an STI, the other based on a per sexual act probability, which takes into account both number of partnerships and differences in male and female transmission. From the per partnership model, they estimated that in 1996 alone, 1,082 new HIV cases in the USA were attributed to syphilis. 2.4.3 STI management for HIV prevention HIV prevention through STI treatment relies heavily on symptomatic episodes that are identified during active infections. Many ulcerative STIs are asymptomatic and the need for treatment is often unrecognized (Korenromp et al., 2000). Mass STI screening for HIV prevention is effective in the early stages of an HIV epidemic, provided that the given population presents with high rates of curable and easily detectable STIs. Beyond that stage, or in populations with untreatable STIs, behavioural changes are necessary (Korenromp et al., 2002).  On an individual level, STI management has been identified to play an important role in reducing HIV transmission (Galvin & Cohen, 2004; Gray et al., 1999; Fleming & Wasserheit, 1999) and infectiousness (Ghys et al., 1997). However, HSV-2 management does not curb HIV seroconversion at the population level when it is solely approached through treatment. Watson-Jones et al. (2008) randomly assigned 821 participants to receive acyclovir to suppress HSV-2 (400 mg twice daily) or a placebo, but no overall reduction in HIV incidence was found (Relative Risk: 1.08 [95% CI: 0.64 to 1.83]).  50 Celum et al. (2008) conducted a double-blind, randomized, placebo-controlled study of HIV negative, HSV-2 seropositive women from three African countries, and men who have sex with men (MSM) in Peru and the USA. Half of the participants were randomly assigned to either daily acyclovir (n=1,637) or placebo (n=1,640) for 12-18 months, and genital examination and HIV testing were performed quarterly. While the incidence of genital ulcers was reduced by 47% in the acyclovir group, this suppression did not result in any reduction in HIV seroconversion. HIV incidence was 3.9 and 3.3 per 100 person-years in both the treatment and placebo groups respectively (HR: 1.16 [95% CI: 0.83-1.62]).  2.5. Summary of the literature  The purpose of this literature review was to provide a comprehensive overview of the literature that is relevant to this dissertation. The review provided a qualitative summary of the available research on sexual health and wellbeing of at-risk Indigenous young people in Canada. It demonstrated that the legacies of colonization have grossly compromised the sexual health of Indigenous people through complex intersections between historic trauma, social marginalization, race, gender, and sexual vulnerability. Drug and alcohol use as a means of coping with ongoing pain further exacerbates such risks. Additionally, stigma, systemic racism in the healthcare system, and the absence of relevant sexual health services obstruct access to sexual health resources. The overrepresentation of Indigenous people among people who have contracted STIs speaks to multiple social and structural barriers to sexual wellbeing. The vulnerability of at-risk Indigenous young people to acquiring ulcerative STIs that increase risk for HIV seroconversion is concerning. Ulcerative STIs cause not only  51 physical ailments, but can result in immense psychological, mental, and emotional distress. Despite the increased risk for contracting ulcerative STIs among people who use drugs, to date, no study in Canada has quantified the prevalence of or risk factors for syphilis or HSV-2 seropositivity among Indigenous people who use drugs.  There is also very little understanding of the historical and lifetime factors that shape sexual behaviours, experiences, understandings or health among Indigenous young people in Canada. The few studies that are available (Anderson, 2002; Devries & Free, 2010; Devries et al., 2009a; Devries et al., 2009b; Devries, 2011; Larkin et al., 2007; McIntyre et al., 2001; Tourand et al., 2016) are largely based on survey data and do not investigate the pathways in which intergenerational trauma or the structure, design, and availability of current sexual health resources are impacting sexual wellbeing. The majority of these studies’ participants were in school, missing potentially critical information from some of the most marginalized young people in society (Thomas, 2016).  The direct and indirect impacts of drug use on STI acquisition are well noted. Indigenous people in Canada are overrepresented among people who self-medicate with drugs (First Nations Information Governance Committee, 2012), and are disproportionately experiencing the factors that increase risk for contracting STIs through drug use. These include – but are not limited to – being involved in survival sex work, having unsafe safe, and transitioning to injection drug use (Chavoshi et al., 2012; Chettier et al., 2010; For the Cedar Project Partnership et al., 2008). As self-medication is a coping mechanism to deal with lifetime stress and ongoing pain (Walters & Simoni, 2002), it is critical to understand the association between historical and social factors,  52 drug use, and sexual wellbeing for at-risk Indigenous young people.  In summary, the paucity of information pertaining to the sexual health risks of Indigenous people who use drugs requires immediate attention. The literature review identified how knowledge gaps continue to limit public health’s capacity to meaningfully support the sexual wellbeing of at-risk Indigenous young people who are coping with adversity. To mitigate these risks, it is imperative to locate these vulnerabilities within the context of unresolved trauma and social marginalization, and how they affect young men and women respectively. To meaningfully develop and deliver sexual health resources, it is critical to identify both the protective factors associated with sexual wellbeing and barriers to access and uptake of services. In order to strengthen relevant resources, we require the wisdom of Indigenous young people to inform the health community of the tools they identify as effective for positive sexual health outcomes and how they might be meaningfully implemented into current programming efforts.            53 Chapter 3: Methodology  This study was nested under the Cedar Project: an ongoing prospective cohort study of Indigenous young people who use drugs in Vancouver, Chase, and Prince George, British Columbia (BC). The quantitative component of this study included primary data collection for HSV-2 and syphilis testing and secondary data from the Cedar Project questionnaires. Participant recruitment, questionnaire data collection, blood sample collection, and data entry were done by Cedar Project staff. The qualitative component involved primary data collection, but Cedar Project staff helped recruit participants and coordinated interview times. The candidate conducted all qualitative interviews, developed the topic guide, and transcribed, coded, and analyzed all data. Cedar Project Partners, mentors, and study members oversaw the analytic approach and interpretation of all findings. The following chapter describes the study design, sampling methodology, data management decisions, research instruments, analytic approaches, and ethical considerations for this project. 3.1. The Cedar Project’s ethical considerations   3.1.1 Partnership with Indigenous collaborators The Cedar Project is funded by the Canadian Institutes for Health Research (CIHR). The Cedar Project enthusiastically embraces the CIHR Guidelines for Health Research Involving Indigenous People and incorporates them into our continued commitments to OCAP (Ownership, Control, Access, and Possession) and the 2010 CIHR Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2). We pay particular attention to Chapter 9, which references health research involving Indigenous people. The principles of these guidelines are supported and  54 advocated for by the Cedar Project Partnership, as they represent self-determination in the research process. The Cedar Project has approval from the University of British Columbia/Providence Healthcare Research Ethics Board (certificate H02-50304). This study has been approved by the University of British Columbia/Providence Healthcare Research Ethics Board as well (certificate H11-01004).  The Cedar Project Partnership is an independent body of Indigenous community experts and knowledge holders who govern and provide oversight to the entire research process, from ethics and study design to the formulation of research questions, conceptual frameworks, data interpretation, media relations, and knowledge translation. The Partnership provides governance, protection, leadership, and support for the Cedar Project, and confirms that the self-determining principles of OCAP are followed. Adhering to the OCAP principles ensures that: 1) the jurisdiction of all Cedar Project knowledge/data/information rests with the Partnership; 2) the relevance of Cedar Project research to Indigenous communities is determined by the Partnership; 3) the sharing of information gained from the Cedar Project evidence base is directed by the Partnership and; 4) a stewardship model is used whereby the Cedar Project database is housed on servers that are protected by firewalls within the Providence Healthcare Research Institute (Vancouver, BC). The Partnership regulates the right to access any Cedar Project information and data.  The Partnership meets every three months to review study protocols, manuscripts, ethics, and emergent data, and to address any issues related to knowledge translation. The governing body provides all Cedar Project researchers with mentorship from Indigenous experts and Elders throughout the research process. This mentorship directs research  55 endeavours through culturally-safe and decolonizing approaches, enriches the interpretation of findings, and ensures that the studies are relevant to Indigenous communities, experts, service providers, and young people who are impacted by the findings. At present, the Cedar Project Partnership is comprised of Indigenous AIDS service providers, members of the community, including Elders, and a representation of on-reserve elected Chiefs. The following entities govern the Partnership on an ongoing basis: Vancouver Native Health, Red Road HIV/AIDS Network, Canadian Aboriginal AIDS Network, Carrier Sekani Family Services, Positive Living North, Prince George Native Friendship Centre, All Nations Hope (Saskatchewan), Splatsin Secwepemc Nation, Neskonlith Indian Band, and Adams Lake Indian Band. In addition, we are honoured by the continued contributions of wisdom support from Elders Violet Bozoki (Lheidli T’enneh Nation) and Earl Henderson (Métis, Cree Heritage). The increasing complexity of this Project has required input and leadership from several additional committees, including a Measurement and Analysis Committee, a Clinical Outcomes Committee, and a Trauma and Resiliency Committee. It should be noted that a Cedar Youth representative has been identified in all three cities. The Cedar Project research assistants are working with all collaborators, governance bodies, and youth representatives to support their participation in the Cedar Project Partnership process. These collaborations are fundamental to the Project’s success.  Knowledge translation and community engagement is a hallmark of the Cedar Project Partnership. For example, with support from a CIHR Dissemination Grant, the Cedar Project Partnership hosted a program of meetings called The Cedar Project: Your  56 Voice Making a Difference, which took place between January-March 2013. This event included a learning potlatch with 250 people including study participants, families, community members, Elders, traditional healers, Indigenous leadership, and health service providers.  3.1.2 Confidentiality and participant care The Cedar Project study team creates a culturally-safe environment for all participants by ensuring all staff are knowledgeable of, and sensitive to the legacies of the residential school and child welfare systems, and the consequent intergenerational traumas that affect the health of Indigenous communities. Participants are invited to spend time at the offices for non-research purposes in order to facilitate a friendly, safe, and comfortable milieu. The Cedar Project staff and research team strive to take time to get to know the participants and build trusting relationships with them. Cedar staff always remind participants that they need only share what they wish to, and that they are never under any pressure to participate in research or discuss subjects with which they are not comfortable. Participants’ safety, health, and comfort are the first priority for all staff.  Staff follow Cedar Project protocols regarding confidentiality, which mandate that all data (questionnaires, forms, etc.) are kept within locked offices with security alarms. Computerized data are made anonymous through the use of numerical IDs and stored at the data management centre at St. Paul Hospital’s Centre for Health Evaluation and Outcome Sciences on secure servers with password and firewall protection. The Centre has state of the art computing facilities with ORACLETM as the main platform and a number of statistical software packages. It has extensive experience with managing large databases of sensitive information (i.e. HIV positive persons) without any breaches of  57 security. Access to data is strictly confined to investigators and staff. The database does not contain any identifying information. To ensure confidentiality we: 1.   Use pseudonyms  2.   Put no identifiers on documents other than study ID 3.   Strictly guard computer access 4.   Have all staff sign confidentiality agreements All information linking participants’ names to their pseudonyms and study IDs is locked in office cabinets that are only accessible to Cedar staff who are responsible for reporting and participant care.  3.1.3 Follow-up care Cedar Project Research Personnel are involved in extensive street-based outreach to provide participants with follow-up opportunities for blood test results. Participants who desire to receive their results are given an appointment by the research nurse, as well as referral for care if requested. In cases where reportability is mandated, Cedar Project nurses contact the participants to come in for a follow-up appointment.  Cedar Project personnel actively provide various sources of support to all participants who have ever been enrolled and involved in the Cedar Project. Resources include, but are not limited to, access to secure housing, traditional healing, and addiction treatment. The Cedar Project routinely maintains contact with participants through street and personal outreach, and invitations to events, get-togethers, and memorials.  For the purposes of this study, the College of Registered Nurses of British Columbia provided Cedar Project staff with information, guidelines, and training materials pertinent to HSV-2 and syphilis counseling and treatment. All participants  58 received pre- and post-test counseling for syphilis and HSV-2 with Cedar Project nurses. Participants who tested positive for HSV-2 and who returned for their test results were provided with decision support tools to assist with treatment, follow-up, and counseling. Partner notification was encouraged, but done at the participants’ discretion.  Before testing for syphilis, participants were advised that a positive test would result in notification to the Provincial Health Services Authority (PHSA) and that antibiotics would be prescribed to treat any cases of untreated syphilis as necessary. Participants were informed that their partners would need to be notified for testing and treatment. PHSA sent all positive syphilis reports to the BCCDC STI/HIV Division where they were entered into the surveillance system. All positive test results were reviewed by the clinic physician and/or Registered Nurse (RN) for diagnosis, treatment recommendations, and partner follow-up. The Cedar Project received copies of all syphilis results.  Only 1 of the 21 positive syphilis cases required treatment (as determined by the reviewing BCCDC clinic physician). BCCDC contacted Cedar Project nurses to discuss follow-up actions. Cedar Project nurses relayed the positive lab results to study participants in person and ensured that participants either received treatment as prescribed by the BCCDC Clinic Physician or had previously completed treatment. Treatment could be done through the Cedar Project or referred to the BCCDC STI outreach team in Vancouver (as all positive cases occurred among participants in Vancouver). Cedar Project nurses counseled all participants regarding partner notification. They also notified BCCDC regarding treatment completion.   59 During data collection, participants were informed that the findings of this study would be made available to them if they were interested. The recommendations presented in Chapter 8 incorporate wisdom gathered at a Cedar Project knowledge translation event that took place in March, 2015. This event was hosted through a CIHR-funded Meetings, Planning and Dissemination grant. The findings of this study were presented, and garnered feedback and direction from Indigenous leaders, participants, and young people on how to incorporate the inherent strengths and cultural resilience of Indigenous people to support sexual safety, education, and health. 3.2 The Cedar Project’s study design, setting, and questionnaires   3.2.1 Cedar Project setting The Cedar Project is a tri-city cohort study located in Vancouver, Prince George, and Chase, BC. In 2006, an estimated 82,000 Indigenous people under the age of 34 were living in BC, almost three-quarters of whom lived off-reserve (BC Statistics, 2006).  The Vancouver Cedar Project office opened its doors in 2003 and has recruited 395 participants to date. Vancouver is the province’s largest metropolitan centre and is located on the unceded traditional territory of the Musqueam First Nation. In 2006, over 40,000 Indigenous people (2.4% of the city’s population) were living in Vancouver (Milligan, 2010b). For over four decades, Vancouver has remained Canada’s epicentre of drug use and survival sex work. The highest concentration of people who use drugs can be found in one of the city’s oldest neighbourhoods, the Downtown East Side (DTES). Over 18,000 people call the DTES home, 10% of whom are Indigenous (City of Vancouver, 2012). Many DTES residents are struggling with substance dependence, mental illness, infectious diseases, and poverty (Adilman & Kliewer, 2000). Indigenous  60 people in the DTES are becoming infected with HIV at twice the rate of non-Indigenous people in the DTES (Craib et al., 2003). The Vancouver Injection Drug Users Study (VIDUS) reported that Indigenous people comprised over 25% of their 1,500 person cohort (Heath et al., 1999). Despite provincial initiatives to increase active antiretroviral therapy and harm reduction efforts, Vancouver had the highest incidence of HIV infections in BC in 2013 (3.2 per 100,000), with Indigenous people disproportionately represented among cases of new infections (BCCDC, 2014).  Prince George is the largest city in BC’s Northern Health Authority (NHA). The NHA has experienced the province’s second highest HIV incidence (2.8 per 100,000), with Indigenous people disproportionately represented among new infection cases (Public Health Agency of Canada, 2015). Prince George is a forestry and mining city, located on the unceded traditional territory of the Lheidli T’enneh First Nation. Its 2006 population was 80,500 people, with 11% identifying as Indigenous (Milligan, 2010a). Prince George is centrally located between two major provincial highways, which has partly contributed to the high rates of violent crimes that the city has experienced due to drug and sex trafficking (Brennan, 2012). Indigenous service organizations and health practitioners who were concerned about the health of their communities, invited the Cedar Project to open an office in downtown Prince George in 2003. Since then, 392 participants have been recruited at this location.  Chase is a rural logging and tourism town located outside the mid-sized city of Kamloops in southwestern BC. While 11% of the town’s 2006 population was comprised of Indigenous people (Statistics Canada Census, 2007), the actual figure at any given time is higher, as many Indigenous people travel frequently between the surrounding  61 First Nation communities in the Kamloops/Chase region. While HIV incidence was below the average provincial rate in 2012 (1.5 vs. 6.5 per 100,000), the incidence of HCV infection was higher (43.6 vs. 42.1 per 100,000) (Interior Health Authority, 2012). Given the disproportionate health risks experienced by Indigenous young people in other parts of the province, the leaders of Secwepemc Nation invited the Cedar Project to open its third office in Chase in 2012. Since then, the Cedar Project has recruited 153 participants in this town.   3.2.2 Cedar Project study design For baseline interviews (ongoing since 2003), eligibility criteria stipulate that participants be between 14 and 30 years of age and have smoked or injected illicit drugs in the month prior to enrolment. Drug use is confirmed using saliva screens (Oral-screen, Avitar Onsite Diagnostics). For the Cedar Project, Indigenous ethnicity is based upon self-reported identification as a descendent of the First Peoples of Canada, and is inclusive of status and non-status First Nations, Métis, and Inuit (for detailed definitions refer to RCAP, 1996, pp. 1-22, Vol.1). Cedar Project staff non-randomly recruit participants through community outreach, referral by healthcare providers, and word of mouth.  All participants meet with one Indigenous study coordinator who explains procedures, confirms study eligibility, and seeks informed consent. All participants are informed of research confidentiality limitations, including the reporting of communicable diseases (HIV, Hepatitis B, C, and tuberculosis) and cases of self-harm and sexual abuse among minors, as required by child welfare legislation. Participants complete interviewer- and nurse-administered questionnaires. Venous blood samples are drawn to  62 test for HIV and HCV antibodies by Cedar nurses, and interviewers are blinded to clinical test results. All participants have private interviews, including pre- and post-test counseling with trained nurses. Each participant receives a $25 honuorarium for their time. Follow-up interviews are conducted every six months.  3.2.3 Cedar Project questionnaires The Cedar Project questionnaires are administered by trained Indigenous and non- Indigenous interviewers and nurses in all three study locations. One Baseline questionnaire is used at enrollment and follow-up questionnaires are administered every six months. This study used cross-sectional data obtained from the baseline questionnaire and follow-up that participants provided blood samples in for HSV-2 and syphilis testing (either Follow-up 16 or 17). The questionnaires elicit data on sociodemographic characteristics, injection and non-injection drug use patterns, sexual practices, service utilization, and experiencing violence. A separate nursing questionnaire assesses participants’ health status by asking clinical questions pertaining to symptoms of infectious diseases, prescribed medications, suicide ideation/attempts, and other general health information. The Cedar Project baseline questionnaire (administered once at enrolment) obtains time-invariant information such as sex (men vs. women), study location (Chase, Prince George, or Vancouver), having biological parents and/or family members who attended residential schools (yes vs. no/unsure), having been taken away from biological parents and placed in foster care (yes vs. no), sexual identity (gay/lesbian/bi-sexual/transgender/queer (GLBTQ) vs. straight) and education level (less than high school vs. high school graduate). Participants were also asked whether the presence of  63 Indigenous culture and tradition during their developmental years played an important role in who they are today (yes vs. no). The follow-up questionnaires include time-varying factors that may have changed in the 6 months between follow-up interviews. Many of these variables are included in the baseline questionnaires but are asked in the context of whether they have ever occurred (vs. whether they have occurred in the past 6 months in follow-up questionnaires). “Living on the street” is defined as having lived on the streets for at least three nights at any point (yes vs. no). “Being incarcerated” is defined as having been placed in prison or jail overnight or longer (yes vs. no).  Drug use questions seek information on injection drug use, type of drug(s) used, bingeing, and overdose experiences. “Heavy alcohol drinking” is defined as drinking four or more times per week. “Binge drug use” is defined as periods where drugs are used more frequently than usual. Injection drug use variables are restricted to participants who have reported ever using injection drugs in their lifetimes (yes vs. no). “Opiate use” includes the use of any of the following drugs: morphine, heroin, methadone, Talwin® (Pentazocine with Naloxone) and/or Dilaudid® (hydromorphone hydrochloride). “Speedballs” are a combination of cocaine and heroin.  The questionnaires include a number of variables that are used to assess sexual vulnerability. “Sexual abuse” is defined as any sexual activity that participants are forced or coerced into (molestation, rape, and sexual assault). Interviewers give this definition to participants prior to asking: “Have you been forced to have sex against your will and/or been molested”? Participants are asked about condom use consistency (always vs. sometimes/never) with regular, casual and/or client partners, and whether they have had  64 an STI (if yes, by type). “Regular partners” are partners with whom a sexual relationship has lasted over three months. “Casual partners” are partners with whom sexual relationships have lasted less than three months. “Clients” are defined as partners with whom sex is traded for survival (e.g. drugs, food, money, shelter, etc.). Other measures of sexual vulnerability include having sex partners who inject drugs and/or are known to be HIV positive.  Variables that may offer protective effects are investigated, and include having accessed alcohol or drug treatment (yes vs. no), having accessed counseling (yes vs. no), and having tried to quit using drugs (yes vs. no). The questionnaires also explore the effects of having participated in any traditional ceremonies (never/rarely vs. often/always). This includes having attended or taken part in ceremonies such as: potlatch, feast, fast, burning ceremony, washing ceremony, naming ceremony, big/smoke house, rites of passage, smudge, and dances.  All questionnaire variables include “unsure” and “refused” as valid response options.  3.3 Dissertation methods The Cedar Project’s focus to date has largely centered on injection related health risks. However, it is now aiming to better understand other health determinants for Indigenous young people living in BC, including the factors that impact sexual wellbeing. This imperative led to the development of the present dissertation, where the prevalence of and risk factors for syphilis and HSV-2 seropositivity as biomarkers for sexual vulnerability were investigated. To expand the examination of sexual health, participants were interviewed about their perceptions of and experiences with sexual wellbeing,  65 education, behaviours, relationships, and sexual health resources. The following section will summarize the quantitative and qualitative methodologies utilized for this dissertation.  3.3.1 Rationale for selecting syphilis and HSV-2 as biomarkers for sexual vulnerability While all STIs can serve as biomarkers for sexual vulnerability, we were limited to choosing those most relevant to, and feasible for the purposes of this study. Testing for STIs such as chlamydia and gonorrhea not only requires an active infection, but involves a sample collection that may be invasive. Syphilis and HSV-2 sample collection involves blood withdrawal, a sampling method that Cedar Project participants have routinely undergone for HIV and HCV testing. Both infections are detectable lifelong and positive serological tests provide evidence of a history of disease.  Among all STIs, syphilis and HSV-2 are deemed to be the most highly associated with increased risk for HIV seroconversion (UNAIDS, 2004). Testing for these two ulcerative STIs and offering participants relevant preventative, treatment, and counseling options may benefit them. The inferences made from the test results will not only quantify the scope of vulnerability to these two STIs, but will allow service providers to identify associated needs and advocate for appropriate resources. After careful consideration of the study’s goals, it was concluded that syphilis and HSV-2 are the most appropriate STIs to assign as biomarkers for sexual vulnerability among Indigenous young people who use drugs.  66 3.3.2 Quantitative data collection During routine interviews (either Follow-ups 16 and 17) from December 2012 through to October 2013, Cedar staff invited Cedar Project participants to partake in an “STI study”. Participants were informed that they would be asked to provide additional blood samples to test for HSV-2 and syphilis. The goals and objectives of the study were communicated by Cedar Project staff, as were the reportability clauses for syphilis positivity and mandatory treatment for untreated syphilis infections. Participants were informed that they would receive a $10 honorarium in addition to the $25 honorarium provided for participating in other elements of the study, and were given an opportunity to ask questions. All participants who were invited to participate agreed to do so.  Informed consent was sought, and participants were given the choice to be tested during routine sample collection for HIV and HCV testing, or to come in for testing at a later time if they wished. The same pre-test counseling, collection, storage, and shipping protocols followed for HIV and HCV testing were followed for HSV-2 and syphilis testing. All test tubes were marked with the study number of each participant, and samples were refrigerated and stored in locked offices before being shipped to the BCCDC High Volume Serology Program in the Central Processing & Receiving Laboratory. The samples were destroyed immediately after clinical testing was completed.   HSV-2 testing was conducted via the Central Processing & Receiving (CPR) Analytical (High Volume Virology) Program for Herpes simplex virus-2 (HSV-2) type-specific serology. Samples were first batch tested for HSV via the Siemens Enzygnost Herpes Simplex assay. Positive samples were type tested using the Focus Diagnostics Herpes Select 2 assay. Syphilis testing was conducted using the Treponema pallidum  67 particle agglutination (TPPA) test. The TPPA has 85-100% sensitivity, and 98-100% specificity to detect primary syphilis, and 98-100% sensitivity for secondary, latent, or tertiary syphilis (Creegan et al., 2007). Indeterminate TPPA results were further tested for recombinant antibodies using the LIA assay. Positive TPPA results were tested with rapid plasma regain (RPR) to determine a past or active infection.  3.3.3 Quantitative data analysis Prevalence rates for Syphilis and HSV-2 and corresponding 95% confidence intervals were calculated for all study participants. Data from the Cedar Project Demographic and Nursing follow-up questionnaires were linked to participants’ blood test results (from samples provided in either Follow-up 16 or 17) to investigate variables associated with HSV-2 and syphilis positivity in separate analyses. Variables included in the analysis were chosen based on not only their statistical significance, but their theoretical relevance and empirical importance to the study’s hypotheses.  HSV-2 analysis  Contingency tables were used to examine associations between HSV-2 seropositivity and several study variables, including demographic characteristics, drug use patterns, and sexual vulnerabilities. Categorical data were explored using Pearson’s chi-squared tests. Fisher’s exact test was used when 25% or more of the expected cell frequencies in a contingency table were less than 5. Means and standard deviations were calculated for continuous variables (e.g. age at enrolment). Student’s t-test was used for comparing the means of different groups. Medians and ranges were calculated for non-normally distributed variables. The Wilcoxon rank sum test was used for comparing the medians of different groups. Because of the known gender differences in sexual risk- 68 taking behavior, parenteral drug use, and lifetime vulnerabilities (Hunt, 2013; Miller, 2002; Spittal et al., 2007), the analysis was stratified by gender to control for any modifying effect this variable may have.  Multivariable logistic regression analysis was used to quantify the unique contribution of each independent covariate after controlling for other covariates of interest from the unadjusted analyses. As many trauma variables are experienced together, multicollinearity among variables considered for multivariate analysis was examined and dealt with accordingly. Similarly, missing values were examined using appropriate statistical techniques (for details, please see section 4.2). The adjusted regression model considered all variables that were statistically associated with HSV-2 seropositivity at p<0.10 in bivariate analysis. Hosmer and Lemeshow (1989) recommend this logistic model building strategy in order to allow researchers to identify variables that may be important but fall outside the predetermined significance range of p<0.05. In addition, any variables that were not found significant but still had empirical or theoretical importance were considered for inclusion in the final models. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated to examine the magnitude and significance of each association before and after controlling for other covariates. All analyses were done separately for men and women.  Syphilis analysis Bivariate analyses were conducted to examine differences in demographic characteristics, drug use patterns, and sexual vulnerabilities among participants who tested positive for a history of syphilis infection and participants who did not. Women living in Vancouver comprised 95% of all positive cases of syphilis (20 of 21 cases). In  69 order to draw meaningful comparisons with participants who tested negative, the analysis of syphilis was restricted by gender (women only) and location (Vancouver only) to control for any confounding effects that these variables may have. The bivariate analyses conducted for HSV-2 analysis were also used for syphilis. Given the proportion of syphilis cases, the sample size was not large enough to accommodate stable multivariate models (Peduzzi et al., 1996). It was therefore deemed not appropriate to perform multivariate modeling in order to determine the variables that were independently associated with a history of syphilis infection. All statistical analyses were performed on SPSS software, version 22.   3.3.4 Qualitative data collection Benefits of a multidisciplinary approach The factors that influence sexual experiences, understanding, and safety for Indigenous young people who use drugs are multifaceted and complex. Qualitative methods “enable health sciences researchers to delve into questions of meaning, examine institutional and social practices and processes, identify barriers and facilitators to change, and discover the reasons for the success or failure of interventions” (Stark & Trinidad, 2007, p. 1). The exploratory and flexible nature of in-depth interviews allows the researcher to not only examine the topic of interest, but to explore and incorporate any new ones that may arise (Schensul et al., 1999). These methodologies have the ability to provide a broader understanding of the interconnected and complex pathways that impact sexual health and can greatly inform quantitative findings. Using in-depth interviews, the voices of Indigenous young people who use drugs were heard to better understand the multifaceted lifetime experiences that impact their  70 sexual experiences, education, and health. Additionally, the sources of strength and protective factors that support sexual wellbeing were identified. Participants were also asked to offer recommendations on how to enhance sexual health resources by identifying barriers to access and uptake of these resources and strategies to overcome them.   Participants were eligible for an in-depth interview if they were enrolled as an active participant of the Cedar Project and had partaken in the quantitative component of this study. This purposive sampling methodology accommodated the exploratory nature of the qualitative inquiry and the goal of confirming patterns in the experience of sexual vulnerability among Indigenous young people who use drugs (Schensul, Schensul, & LeCompte, 1999). This approach allowed us to triangulate findings of the broader dissertation and add richness and rigour to the analyses. Methodology triangulation permits researchers to use more than one approach in a research inquiry to produce a deeper understanding of the complementary facets of an investigated phenomenon (Patton, 1999). The two methods were meant to inform one another: while the epidemiological study aimed to investigate determinants of sexual health by quantifying the prevalence of and risk factors for ulcerative STIs, the qualitative methods allowed the researcher to seek an understanding of how these various factors (and other factors) impact sexual health. Such triangulation of methods strengthens both the reliability and validity of the analytic evaluation (Golafshani, 2003; Patton, 1999). Using qualitative observations allowed the researcher to validate the epidemiological findings that emerged in the investigation of HSV-2 and syphilis positivity and to facilitate an opportunity to generate new hypotheses that could be tested quantitatively if need be.   71 Participant recruitment and interviews  Cedar Project staff at the Vancouver office informed potential participants that a female doctoral student was interested in conducting an in-depth, open-ended interview to ask questions about their understandings and experiences around sexual education, encounters, and health, and to obtain recommendations on how to enhance resources that would support their sexual wellbeing. Cedar Project staff have excellent rapport with participants, and extended these invitations to those whom they felt would be willing to discuss matters of sexuality with a female student.   Participants were informed that they would receive an additional $20 honorarium for starting the interview process, even if they chose to terminate the interview. A sign-up sheet with preferred interview appointment times was made available. Participants were given appointment cards with their interview time as a reminder. To increase participants’ comfort, they were given the option of having another Cedar Project staff member sit in on the interview with them. All participants declined this option. The interviews were conducted at the Vancouver Cedar Project office during both open and closed hours.    N.C. spent non-research related time at the Vancouver offices between interviews where she was introduced to participants by Cedar staff. During these sessions, the researcher aimed to develop rapport with participants and have her presence as a Cedar Project team member known. A total of 28 participants signed up over the course of six months (May-November, 2013). In-depth responses were obtained from 28 interviewees: 13 were young men, 15 were young women; 17 were based in Vancouver, and 11 were based in Prince George. The very first interview was facilitated by Nancy Laliberte, a  72 qualitative researcher of Métis ancestry with a rich experience of interviewing Cedar Project participants. Ms. Laliberte approved N.C.’s interviewing techniques and provided feedback, training, and guidance on how to approach and conduct future interviews.  Written consent was obtained from participants prior to commencing the interview. Participants were given time to review the detailed consent form and N.C. reemphasized the limitations regarding the disclosure of harm to a child before the form was signed. Throughout the interviews, any observed differences in N.C.’s socioeconomic status, gender, culture, or ethnic background may have led participants to withhold sensitive or personal information (Patton, 1999). The interviewer aimed to overcome any such barriers by dressing casually and consistently maintaining an atmosphere of comfort throughout the course of the discussions. N.C. strove to facilitate casual, safe, open, friendly conversations by mirroring traditional storytelling practices and emphasizing the value of the participants’ contributions to the study’s goals.    A loosely structured topic guide directed the interviews. The topic guide was informed by the available literature and research framework of this study. The guide was developed by N.C. and Cedar Project staff (interviewers and nurses), and finalized with Dr. Shannon Waters (Stz'uminus First Nation) and Janine Stevenson (RN). Dr. Waters is a Cedar Project Partner, the Medical Director of Vancouver Island Health, Aboriginal Physician Advisor to the Provincial Health Officer, and a former Senior Medical Officer of the First Nations Health Authority. Dr. Waters is also a Cedar Project knowledge user, and her practice focuses on sexual and maternal health for Indigenous young people. Janine Stevenson is a Registered Nurse with the First Nations Health Authority and BCCDC STI division. Ms. Stevenson has extensive experience working with Indigenous  73 young people as a Street Outreach Nurse in the DTES, and is knowledgeable of Indigenous community health and wellness, with particular focus on sexual health and harm reduction.  The topic guide included the following areas of exploration: a) unraveling the influences of residential school histories and intergenerational trauma on sexual experiences, education, and safety; b) tracing the influence of family, school, peers, sexual partners, and drug use on sexual development, education, relationships, and experiences; c) exploring risk taking or risk minimizing behaviours; d) understanding experiences with STIs; e) identifying social and structural barriers to sexual safety and health and to accessing preventative/treatment services; and f) identifying key resources that support healthy sexual development and wellbeing for Indigenous young people who face adversity, and how current ones can be improved. Categories of exploration were kept as broad as possible to allow relational understandings to emerge about both risk and protective factors participants associated with sexual vulnerability.   The interviewer memorized the topic guide well in advance to allow for a natural conversation to occur. The participants were asked to simply tell their story. The interviews were loosely structured to allow responses to flow inductively through the participants’ narratives, and sensitive probing on difficult topics helped detailed discussions to proceed. This approach is appropriate as loosely structured opened-ended interviews allow flexibility to discuss any new topics that may arise (Schensul et al., 2009). Indigenous young people often use storytelling to illustrate the sequence of life events that have shaped their past and present (Brant Castellano, 2000; Kovach, 2010; Tousignant & Sioui, 2009) and this approach permits them to express their narratives as a  74 logical unraveling of their accumulated lifetime experiences.   All interviews were recorded using a digital recording device and lasted between 30 minutes and 2.5 hours. The researcher took extensive field notes after each interview to capture any observations that may have been missed on the audio recording and to document any insights, thoughts, questions, and comments that may have arisen during the course of the interview. Frequent debriefing sessions with Cedar Project mentors allowed the researcher to evaluate these considerations with integrity.  Positionality and reflexivity   It is important to discuss the role of positionality and how it may have impacted the researcher’s qualitative approach, interview methods, and decision-making. The researcher brought her ways of knowing both as a student who has been trained in western research methods and as an immigrant and former war-displaced refugee who has lived in five different countries and fifteen different homes. Her personal experiences with displacement, discrimination, political injustice, bullying, racism, illness, and marginalization peaked her interest in critically engaging in research that assesses the intersections of class, ethnicity, gender, cultural differences, and power imbalances in health inequities (LeCompte & Schensul, 1999).   As required by LeCompte et al. (1999), a central priority for the researcher was to rigorously self-reflect on her personal biases, and regularly examine if and how they could be influencing her research methods. This self-awareness is a necessary component of qualitative research, and boosts the credibility of the researcher (Koch, 1994). The researcher aimed to be not only reflexive, but exercise cultural humility through her research process. Cultural humility is defined as “a process of self-reflection and self- 75 critique to understand personal biases and to develop and maintain mutually respectful partnerships based on mutual trust” (First Nations Health Authority, 2016b). To assess reflexivity and strengthen her ability to practice cultural humility, a log of observations was kept in a field journal that included extensive notes on her thoughts and reactions during the interviews and analytic process (Koch, 1994). Frequent conversations with Cedar Project Partners and mentors allowed the researcher to assess her perspective and ensure that she was meaningfully forming relationships with the ideas that were being studied. In doing so, the researcher aimed to hold herself accountable to the Cedar Project Partners and the participants who entrusted her with their stories (Wilson, 2008). 3.3.5 Qualitative data analysis  The data was analyzed using N-Vivo 10, a computer software package designed for organizing and coding qualitative data. An interpretive thematic approach informed the analysis of the data (Starks & Trinidad, 2007). This approach supported a detailed interpretation of responses in relation to each research question and subject of interest (Braun & Clark, 2006), and allowed the researcher to engages as a witness of the accounts of lifetime experiences that protected against and increased risk for sexual vulnerability. All data was transcribed verbatim and reread carefully by the researcher so that she could become familiar with the body of information in order to identify patterns, evaluate contradictions, and explore assumptions.   Codes were created by grouping specific statements into meaningful categories. When the data was collapsed, the researcher paid special attention to the what, how and why components of the feelings, actions, and experiences described in participants’ statements (Stark & Trinidad, 2007). Using the ‘constant comparison method’, the  76 produced data was analyzed inductively. This approach gave each described incident an opportunity to be reflected as a concept (LeCompte & Schensul, 1999), and allowed central themes to be drawn across the body of narratives (Starks & Trinidad, 2007). Codes were combined into overarching themes that represented the data and fit within the framework informing the study. All decisions made regarding the identification and categorization of coding and themes were carefully recorded to allow for an inquiry audit to increase the dependability of the analytic process (Golafshani, 2003; Koch, 1994). Reflective quotes were drawn from the transcripts to illustrate the conceptual patterns and derived themes. Pseudonyms were used to protect the identity of the participants. The researcher constantly evaluated themes to ensure the stories were analyzed coherently and distinctively, and illustrated by excerpts that fit the analytic claims (Braun & Clark, 2006). Context for each illustrative quote was provided to allow for the judgement of transferability to be made by the reader (Koch, 1994).   The researcher continually presented her analytic approach and findings to committee members and Cedar Project mentors in order to address assumptions, generate hypotheses and gather feedback. All analytic claims were compared to existing Cedar Project findings in order to map out congruence or contradictions with previously collected/analyzed data. These methods enriched the rigour, quality, and trustworthiness of the analysis (Golafshani, 2003; Koch, 2010; Stark & Trinidad, 2007). The coding scheme, thematic analysis, and interpretations were presented to Cedar Project Partners in March, 2015 for recommendations and approval.     77 Chapter 4: The prevalence and correlates of Herpes Simplex Virus 2 in a cohort of Indigenous young people who use drugs in British Columbia, Canada  4.1 Introduction The determinants of health include social, cultural, economic, and environmental factors that impact the overall wellbeing of an individual or community (World Health Organization). Health disparities result when these determinants are compromised. In Canada, Indigenous communities have been subjected to historical, structural, and social barriers to wellbeing for over 500 years. European colonizers who sought to control Indigenous peoples’ land and resources systemically attacked their self-determination through forced removal from traditional lands, cultural genocide, and apprehension of their children. The devastating consequences of colonization continue to impede wellbeing through ongoing pain, and social and racial marginalization (Red Road HIV/AIDS Network, 2006; First Nations Health Authority, 2013; Wesley-Esquimaux & Smolewski, 2004).  In particular, the legacies of the residential school and child welfare systems have severely impacted the sexual wellbeing of Indigenous communities (Farmer et al., 1996; Vernon, 2001). In the residential schools, Indigenous children were subjected to widespread sexual abuse, and the Indigenous wellness frameworks that historically upheld sexual wellbeing were systemically dismantled (TRC, 2015). Consequently, Indigenous communities are experiencing disproportionate rates of sexual violence, HIV/AIDS, involvement in survival sex work, and STIs (BCCDC, 2013; For the Cedar Project Partnership et al., 2008; Native Women’s Association of Canada, 2010; Public Health Agency of Canada, 2015; Sikka, 2009; Steenbeck et al., 2006). Indigenous leaders and scholars stress that any examination of the present-day sexual health challenges that  78 Indigenous people face must move away from individual risk behaviours and focus on the complex health determinants that stem from colonization and intergenerational trauma (Christian & Spittal, 2008; Duran & Walters, 2004; Vernon, 2001; Walters et al., 2011).  It is difficult to establish the precise magnitude of STI morbidity faced by Indigenous people, as ethnicity is often not reported in surveillance data. Among STIs, international research demonstrates that the biological pathways of ulcerative STIs, such as Herpes Simplex Virus Type 2 (HSV-2), increase the likelihood of acquiring HIV infection by 2-3 fold (Freeman et al., 2006, Wald et al., 2002). Often, this STI is asymptomatic, and many individuals are not aware of their serostatus (BCCDC, 2007). Genital herpes is the second most prevalent STI and the most common cause of genital ulceration in Canada (BCCDC, 2009). While HSV-1 can cause genital ulcerations, genital herpes is predominantly attributed to the HSV-2 strain (BCCDC, 2007; WHO, 2016). The overrepresentation of Indigenous people in terms of both the prevalence and incidence of HSV has been monitored and documented internationally (Brazzale, et al., 2010; Butler et al., 2000; Communicable Disease Control Directorate Department of Health, 2010). However, there are no estimates of HSV-2 prevalence for Indigenous people in Canada.  The use of illicit drugs to numb the immense pains of self-loss endured by Indigenous people who face adversities exacerbates the risk of experiencing negative sexual health outcomes (Gesink et al., 2016; Kendler et al., 2000). Still, very little research has investigated the interaction between historical trauma, self-medication, and sexual risk among Indigenous people in Canada. The dearth of information pertaining to  79 the health of Indigenous people who use drugs led to the development of the Cedar Project: an Indigenous governed cohort study among Indigenous young people who use illicit drugs in British Columbia (BC). Examinations of HIV and Hepatitis C (HCV) infection among Cedar Project participants have provided in-depth understandings of the historical and lifetime experiences that increase vulnerability to these infections (Craib et al., 2009; Mehrabadi et al., 2008b; Spittal et al., 2007; Spittal et al., 2011). To date, the focus of the Cedar Project has largely centered on injection related health risks. Now, the Project aims to better understand the sexual acquisition of infectious diseases. HSV-2 is an effective biomarker that merits such attention, as it is highly prevalent, is only transmitted through sex, and is detectable through blood sampling at any point subsequent to infection. To address the knowledge gap pertaining to the prevalence and correlates of HSV-2 seropositivity among Indigenous young people who use drugs, this study extended routine HIV and HCV testing among Cedar Project participants to include HSV-2. This ulcerative STI will serve as a biomarker of sexual vulnerability for Indigenous young people who use drugs. Therein, the study will help meaningfully situate sexual health risks within the context of historical trauma among Indigenous young men and women who continue to demonstrate strength and resilience in the face of adversity. 4.2 Methods  4.2.1 The Cedar Project study design The Cedar Project is an ongoing prospective cohort study among young Indigenous men and women who use drugs in Vancouver, Prince George, and Chase, BC. The study includes data from the 250 participants who completed the follow-up  80 questionnaires between December 2012 and October 2013. The Cedar Project’s enrollment eligibility criteria stipulate that participants be of self-reported Indigenous ancestry, be between the ages of 14 and 30 at the time of study enrolment, and have smoked or injected illicit drugs one month prior to enrolment. Please refer to Chapter 3.2 for complete details on the Cedar Project’s study methods, recruitment, data variables, and questionnaires.   4.2.2 Data collection  During the Cedar Project’s 16th and 17th round of follow-up interviews, research staff invited participants to partake in an “STI study” that aimed to quantify the prevalence and correlates of HSV-2. Participants were informed that they could provide an additional vial of blood to test for HSV-2 during routine blood sample collection for HIV and HCV testing by Cedar Project nurses. They were told that a $10 honorarium would be offered for participating in the study. Participants were given the opportunity to ask questions and to review the consent form.  The College of Registered Nurses of British Columbia provided Cedar Project staff with information, guidelines, and training materials pertinent to HSV-2 treatment and counseling. To uphold our commitment to participant care and safety, all participants received pre-test counseling by Cedar Project nurses. Cedar Project Research Personnel are involved in extensive street-based outreach to provide participants with follow-up opportunities for blood test results. Participants who desired to receive their results were given an appointment by the research nurse, as well as support tools to assist in decision-making and referrals for treatment and follow-up care. Partner notification was encouraged, but done at participants’ discretion. Please refer to Chapter 3.1 for specific  81 details on participant care and follow-up, and the confidentiality and ethical protocols followed by the Cedar Project.  The protocols to collect, store, and ship blood samples that were followed for routine HIV and HCV testing were also followed for HSV-2 testing. Test tubes were marked with each participant’s study number, and were refrigerated and stored in locked offices prior to being shipped to the Central Processing & Receiving Laboratory of the British Columbia Centre for Disease Control (BCCDC) High Volume Serology Program. HSV-2 testing was conducted via the Central Processing & Receiving (CPR) Analytical (High Volume Virology) Program for HSV-2 type specific serology. Samples were first batch tested for HSV via the Siemens Enzygnost Herpes Simplex assay. Positive samples were type tested using the Focus Diagnostics Herpes Select 2 assay. All samples were destroyed immediately after testing was completed.   4.2.3 Statistical analysis  Prevalence rates for HSV-2 and corresponding 95% confidence intervals were calculated for the entire cohort, then separately for men and women. Data from the Cedar Project Demographic and Nursing Follow-up questionnaires were collected for each participant who provided blood samples (in either Follow-up 16 or 17). Questionnaire data from the Follow-up in which blood was provided in were linked to participants’ blood test results to investigate the correlates of HSV-2 positivity. Chapter 3.2.3 includes complete details on the variables that were considered for this study.  Contingency tables were used to examine associations between HSV-2 seropositivity and several study variables, including demographic characteristics, drug use patterns, and sexual vulnerabilities. Categorical data were explored using Pearson’s  82 chi-squared tests. Fisher’s exact test was used when 25% or more of the expected cell frequencies in a contingency table were less than 5. Means and standard deviations were calculated for continuous variables (e.g. age at enrolment). Student’s t-test was used for comparing the means of different groups. Medians and ranges were calculated for non-normally distributed variables. The Wilcoxon rank sum test was used for comparing the medians of different groups. Because of the known gender differences in sexual risk-taking behavior, parenteral drug use, and lifetime vulnerabilities (Hunt, 2013; Miller, 2002; Spittal et al., 2007), the analysis was stratified by gender to control for any modifying effect this variable may have.  Multivariate logistic regression analysis was used to quantify the unique contribution of each independent covariate after controlling for other covariates. The multivariate model considered all variables that were statistically associated with HSV-2 seropositivity at p<0.10 in the bivariate analysis. In addition, any variables that were not found significant at p<0.10 but still had empirical or theoretical importance to the study’s hypotheses were considered for inclusion in the final models. Hosmer and Lemeshow (1989) recommend this logistic model-building strategy because it allows researchers to identify variables that fall outside a predetermined significance range, but may still be important. Handling missing data  Variables considered for inclusion in the adjusted models were examined for missing data. Among women, all covariates of interest had 100% response rate, with the exception of having a mother who attended residential school. This question had 74.1% respondents answer either “yes” or “no”; the remaining 25.9% answered “unsure”. In a  83 separate analysis, respondents who answered “unsure” to this question were treated as missing cases to test whether they significantly differed from those who answered “yes” or “no”. Little’s MCAR (missing cases at random) test was used to assess the randomness of missing values. The p-value for Little's MCAR test was not significant (p=0.28). The respondents who answered “unsure” may therefore be assumed to not significantly differ from those who responded “yes” or “no”. For this model, listwise deletion of observations with missing values was appropriate (Little, 1998). Separate adjusted models were fit for participants that answered “yes/no” and “unsure”, and compared to assess whether excluding “unsures” impacted the multivariate results. No changes in the direction or significance of covariates was found between stratified analyses. As such, the model that is presented (Table 4.4) includes only women who answered either “yes” or “no” to having a mother who attended residential school (n=106). For men, having culture play an important role in development and ever having been sexually abused had 96.3% and 95.3% response rates, respectively (combined response rate of 91.6% for both variables). The remaining variables had 100% response rates. A missing rate of less than 10% is not likely to bias results (Bennett, 2001), therefore the model that is presented (Table 4.6) only includes participants that answered either “yes” or “no” to both these questions (n=98). Handling multicollinearity  As many trauma variables are interrelated and experienced simultaneously, multicollinearity testing was done between covariates considered for multivariate analysis. For women, two adjusted models were built (Tables 4.4 and 4.5). This was done to avoid placing any correlated variables within the same model. This approach helped  84 avoid diminishing the effect of potentially significant associations by not including mediators in the model.  For women, two variables were omitted from the final models altogether due to their correlation with multiple covariates. Ever being on the street for more than 3 nights was correlated with survival sex work, having ever used injection drugs, and living in Vancouver. Ever being on the street for more than 3 nights was therefore removed from multivariate modelling. Smoking crack in the past 6 months was correlated with survival sex work, having been taken away from biological parents, and having ever used injection drugs. Because smoking crack in the past 6 months was only marginally significant in the bivariate analysis, it was excluded from the multivariate analysis. The decision to omit these two variables was based on their theoretical importance relative to the variables they were correlated to. Overall, these methods intended to best explain the unique contributions of the constellation of highly correlated risk factors that are associated with HSV-2 infection.  Unadjusted and adjusted odds ratios of each covariate were compared in all final models, and no concerning changes in their direction or magnitude were found. All analyses were conducted on SPSS statistical software package, version 22.  4.3 Findings Of the 250 participants tested for HSV-2 seropositivity in the Cedar Project cohort, 57% were women, and 42% lived in Vancouver. After clinical testing, 61% [95% CI: 55%-67%] of participants were found to be seropositive, 74% of whom were women. The odds of testing positive among women was 6.52 times [95% CI: 3.74-11.53] that of men.  85 4.3.1 HSV-2 seropositivity among women   Among all women (n=143), 79% [95% CI: 72%-86%] tested positive for HSV-2. Only 9% of the women who tested seropositive self-reported HSV-2 positivity and 8% reported ever having an outbreak (Table 4.2). In bivariate analyses, historical and lifetime variables that were significantly associated with HSV-2 positivity included having been taken from biological parents (73% vs. 47%; p<0.01), having a mother who attended residential school (59% vs. 35%; p=0.04), ever having slept on the street for 3 or more nights (64% vs. 40%; p=0.02) (Table 4.1), and ever having been involved in survival sex work (68% vs. 40%; p<0.01) (Table 4.2). With respect to drug use, women who tested positive for HSV-2 were significantly more likely to have ever injected drugs (59% vs. 30%; p<0.01), and reported heavy alcohol drinking (74% vs. 53%; p=0.03) (Table 4.3).  Variables that had marginally significant associations with HSV-2 positivity included living in Vancouver (44% vs. 27%, p=0.08), HCV (40% vs. 23%; p=0.09); syphilis (18% vs. 0%; p=0.08), and HIV positivity (18% vs. 3%; p=0.08); ever being pregnant (74% vs. 57%; p=0.10); and smoking crack in the past 6 months (82% vs. 62%, p=0.10). When compared to women who tested seropositive for HSV-2, those who tested seronegative were marginally less likely to report condom use with a casual partner (25% vs. 83%, p=0.05) and with clients (50% vs. 100%, p=0.09) (Table 4.2). In multivariate analyses, HSV-2 positivity among women was significantly associated with having been taken from biological parents (Adjusted Odds Ratio: 3.25, 95% Confidence Interval [1.34-7.88]); ever being involved in survival sex work (AOR: 3.15 [95% CI: 1.13-8.79]); and ever having injected drugs (AOR: 3.39 [95% CI: 1.32- 86 8.67]). Variables that were marginally significant included drinking alcohol heavily (AOR: 2.37 [95% CI: 0.99-5.65]) and having a mother who attended residential school (AOR: 2.52 [95% CI: 0.90-7.09]) (Tables 4.4 and 4.5). 4.3.2 HSV-2 seropositivity among men  Among all men (n=107), 36% [95% CI: 30%-48%] tested seropositive for HSV-2. Among them, only 8% self-reported HSV-2 positivity or ever having an outbreak (Table 4.2).  In bivariate analyses, men who tested positive for HSV-2 were significantly more likely to have ever been in prison (79% vs. 54%; p<0.01) and self-report ever having an STI (54% vs. 25%; p<0.01) (Table 5.2). Marginally significant associations with HSV-2 positivity included living in Vancouver (56% vs. 38%, p=0.07) and having a history of sexual abuse (36% vs. 23%, p=0.10). Participants who stated that culture played an important role during their developmental years were marginally less likely to test HSV-2 seropositive (40% vs. 59%; p=0.07) (Table 4.1). In multivariate analysis, HSV-2 positivity among men was significantly associated with ever having been in prison (AOR: 2.99 [95% CI: 1.11- 8.07]). Having culture play an important role in development was found to have a significant protective effect on HSV-2 positivity (AOR: 0.41 [95% CI: 0.19-1.00]) (Table 4.6).       87 Table 4. 1: Comparison of demographic and traumatic life events among women who tested positive for HSV-2 (n=113) vs. women who tested negative (n=30); and men who tested positive for HSV-2 (n=39) vs. men who tested negative (n=68)  Women   Men  Variable  HSV-2 + N (%) HSV-2 - N (%) p-value  HSV-2 + N (%) HSV-2 - N (%) p-value  Baseline interview location  Vancouver Prince George/Chase  50 (44%) 63 (56%)  8 (27%) 22 (73%)  0.08  22 (56%) 17 (44%)  26 (38%) 42 (62%)  0.07 Mean age  (SD) 23.0 (4.17) 21.4 (4.16) 0.07 24.3 (3.76) 22.6 (4.59) 0.04 Sexual identity LGBTQ 11 (10%) 5 (17%) 0.28 4 (10%) 6 (8%) 0.99 Father attended residential school 39 (53%) 8 (33%) 0.09 11 (48%) 22 (51%) 0.79 Mother attended residential school 49 (59%) 8 (35%) 0.04 12 (50%) 20 (42%) 0.50 Ever taken from biological parents  82 (73%) 14 (47%) <0.01 25 (64%) 40 (59%) 0.59 Relationship status not single 49 (54%) 5 (42%) 0.41 13 (42%) 21 (45%) 0.81 Ever on streets for >3 nights  72 (64%) 12 (40%) 0.02 28 (72%) 39 (57%) 0.14 Ever on streets for >3 nights  past 6 months 17 (19%) 0 (0%) 0.12 6 (19%) 13 (27%) 0.39 Ever been in prison  59 (78%) 14 (74%) 0.64 31 (79%) 37 (54%) <0.01 Been in prison since last visit  13 (72%) 2 (50%) 0.99 7 (22%) 16 (33%) 0.99 Ever attempt suicide 38 (70%) 9 (75%) 0.99 11 (58%) 15 (56%) 0.86 Ever diagnosed mental illness 27 (24%) 8 (28%) 0.69 15 (39%) 20 (29%) 0.34 Ever received counseling 31 (44%) 8 (57%) 0.38 8 (50%) 6 (38%) 0.48 Counseling past 6 months 19 (21%) 4 (29%) 0.51 4 (13%) 12 (26%) 0.25 Ever been denied services due to  drug use  20 (18%) 3 (10%) 0.41 5 (13%) 11 (16%) 0.68 Ever been denied shelter due to  drug use  23 (21%) 2 (7%) 0.10 6 (15%) 15 (22%) 0.40 Experienced violence past 6 months 15 (17%) 1 (7%) 0.69 7 (22%) 8 (17%) 0.56 Did not graduate high school 92 (82%) 25 (83%) 0.88 28 (72%) 54 (79%) 0.37 Culture played an important role in  developmental years 14 (15%) 2 (14%) 0.92 15 (40%) 39 (59%) 0.07 Participated in Traditional  ceremonies past 6 months 49 (48%) 3 (21%) 0.12 9 (28%) 12 (25%) 0.76                88 Table 4. 2: Comparison of sexual vulnerabilities among women who tested positive for HSV-2 (n=113) vs. women who tested negative (n=30); and men who tested positive for HSV-2 (n=39) vs. men who tested negative (n=68)  Women  Men Variable  HSV-2 + N (%) HSV-2 - N (%) p-value   HSV-2 + N (%) HSV-2 - N (%) p-value  Median (range) (for women)  Mean (SD) (for men) age of first willing sex  14 (10-22) 15 (12-21) 0.39 15.3 (2.53) 14.6 (1.72) 0.14 Median age of first sexual abuse  (range) 6 (1-18) 9.5 (2-18) 0.16 5 (2-10) 6 (2-13) 0.39 Ever sexually abused 69 (62%) 14 (50%) 0.26 14 (36%) 15 (23%) 0.10 Sexually abused past 6 months  4 (4%) 0 (0%) 0.99 0 (0%) 1 (2%) 0.99 Ever involved in survival sex 77 (68%) 12 (40%) <0.01 3 (10%) 3 (6%) 0.66 Survival sex past 6 months 27 (34%) 2 (22%) 0.71 2 (13%) 1 (4%) 0.55 Ever been pregnant  76 (74%) 13 (57%) 0.10 N/A N/A N/A Pregnant in last 6 months  12 (14%) 3 (25%) 0.39 N/A N/A N/A Ever had an abortion  28 (35%) 5 (33%) 0.88 N/A N/A N/A Abortion since last visit 12 (14%) 3 (25%) 0.25 N/A N/A N/A Condom use for insertive sex with  regular partner* 16 (26%) 1 (14%) 0.67 1 (15%) 5 (21%) 0.99 Regular sex partner uses injection  drugs* 11 (18%) 0 (0%) 0.59 3 (23%) 6 (24%) 0.99 Regular sex partner HIV+*  7 (13%) 0 (0%) 0.99 1 (8%) 2 (8%) 0.99 Casual sex partner HIV+*  (13 unsure) 1 (3%) 0 (0%) 0.99 1 (8%) 2 (10%) 0.99 Condom use for insertive sex with  casual partner ** 15 (83%) 1 (25%) 0.05 6 (40%) 7 (44%) 0.99 Casual sex partner uses injection  drugs ** 1 (6%) 0 (0%) 0.99 3 (23%) 5 (36%) 0.68 Condom use for insertive sex with  clients *** 19 (100%) 1 (50%) 0.09 2 (100%) 0 (0%) 0.33 Offered money not use condom*** 52 (81%) 6 (60%) 0.21 0 (0%) 0 (0%) N/A Accepted money to not use condom*** 15 (29%) 3 (50%) 0.36 0 (0%) 0 (0%) N/A  89 Table 4. 2 (continued): Comparison of sexual vulnerabilities among women who tested positive for HSV-2 (n=113) vs. women who tested negative (n=30); and men who tested positive for HSV-2 (n=39) vs. men who tested negative (n=68)  Women  Men Variable  HSV-2 + N (%) HSV-2 - N (%) p-value   HSV-2 + N (%) HSV-2 - N (%) p-value  Use drugs with clients*** 12 (44%) 1 (50%) 0.99 1 (50%) 0 (0%) 0.99 Ever had a bad date*** 5 (19%) 0 (0%) 0.99 2 (100%) 0 (0%) 0.99 Ever had STI 67 (59%) 19 (63%) 0.69 21 (54%) 17 (25%) <0.01 Had an STI in the past 6 months 7 (8%) 2 (17%) 0.31 2 (7%) 0 (0%) 0.16 Ever treated for STI 63 (55%) 13 (43%) 0.08 15 (38%) 9 (13%) <0.01 Ever had an outbreak 9 (35%)  2 (67%) 0.53 3 (43%) 1 (11%) 0.26 Self-reported chlamydia  52 (46%) 9 (30%) 0.12 8 (21%) 7 (10%) 0.15 Self-reported gonorrhea   16 (14%) 2 (7%) 0.36 3 (8%) 2 (3%) 0.35 Self-reported HSV-2  10 (9%) 0(0%) 0.12 3 (8%) 0 (0%) 0.05 Self-reported syphilis  9 (100%) 3 (16%) <0.01 1 (3%) 1 (2%)  0.99 History of syphilis 20 (18%) 0 (0%) 0.08 1 (3%) 0 (0%) 0.40 HIV+ 20 (18%) 1 (3%) 0.08 6 (15%) 6 (9%) 0.31 HCV+ 45 (40%) 7 (23%) 0.09 12 (31%) 12 (18%) 0.12 Pap smear in the past 6 months 88 (99%) 12 (100%) 0.99 N/A N/A N/A Abnormal pap 16 (18%) 1 (8%) 0.69 N/A N/A N/A Regular pap smears 67 (76%) 9 (82%) 0.99 N/A N/A N/A On birth control 54 (61%) 7 (58%) 0.88 N/A N/A N/A  *    Restricted to participants who reported having regular sex partners  **  Restricted to participants who reported having casual sex partners  ***Restricted to participants who reported having clients            90 Table 4. 3: Comparison of drug related vulnerabilities among women who tested positive for HSV-2 (n=113) vs. women who tested negative (n=30); and men who tested positive for HSV-2 (n=39) vs. men who tested negative (n=68)  Women  Men Variable  HSV-2 + N (%) HSV-2 - N (%) p-value   HSV-2 + N (%) HSV-2 - N (%) p-value  Ever overdose 31 (28%) 7 (23%) 0.62 8 (21%) 23 (34%) 0.17 Overdose past 6 months 4 (12%) 0 (0%) 0.99 1 (17%) 0 (0%) 0.30 Heavy alcohol drinking  83 (74%) 16 (53%) 0.03 24 (62%) 49 (72%) 0.26 Blackout past 6 months 23 (44%) 5 (56%) 0.72 9 (36%) 17 (43%) 0.60 Non-injection drugs past 6 months 71 (78%) 13 (93%) 0.29 22 (69%) 38 (81%) 0.22 Crack smoking past 6 months 61 (82%) 8 (62%) 0.10 17 (71%) 22 (58%) 0.30 Cocaine smoking past 6 months 20 (27%) 2 (15%) 0.50 7 (29%) 8 (21%) 0.47 Crystal smoking past 6 months 21 (28%) 3 (23%) 0.99 8 (33%) 20 (53%) 0.14 Heroin smoking past 6 months 9 (12%) 1 (8%) 0.99 5 (21%) 4 (11%) 0.29 Binge non-injection drug use  past 6 months  25 (41%) 3 (27%) 0.51 4 (21%) 6 (21%) 0.98 Ever inject drugs 67 (59%) 9 (30%) <0.01 19 (49%) 25 (37%) 0.25 Inject drugs past 6 months 37 (55%) 4 (45%) 0.35 13 (33%) 16 (24%) 0.22 Binge injection drug use ^ past 6 months  5 (15%) 0 (0%) 0.99 3 (25%) 3 (20%) 0.99 IV crack past 6 months^ 1 (6%) 0 (0%) 0.99 9 (69%) 7 (44%) 0.21 IV crystal past 6 months^ 15 (41%) 1 (25%) 0.99 9 (69%) 14 (88%) 0.36 IV cocaine past 6 months^ 10 (27%) 1 (25%) 0.99 4 (31%) 2 (13%) 0.36 IV heroin past 6 months^ 25 (68%) 2 (50%) 0.59 8 (62%) 7 (44%) 0.34 IV morphine past 6 months^ 12 (32%) 0 (0%) 0.30 5 (39%) 5 (31%) 0.68 IV dilaudid 6 months^ 10 (27%) 0 (0%) 0.56 4 (31%) 5 (31%) 0.98 IV speedballs past 6 months^ 4 (11%) 0 (0%) 0.99 1 (7%) 4 (25%) 0.34 Ever need help injecting^ 38 (75%) 6 (86%) 0.99 12 (80%) 12 (57%) 0.28 Need help injecting past 6 months^ 10 (29%) 1 (17%) 0.99 2 (17%) 10 (83%) 0.41 Ever use INSITE^ 16 (47%) 2 (50%) 0.99 7 (58%) 9 (60%) 0.99 Drug or alcohol treatment  past 6 months 39 (43%) 6 (43%) 0.97 11 (34%) 13 (27%) 0.49   91 Table 4. 3 (continued): Comparison of drug related vulnerabilities among women who tested positive for HSV-2 (n=113) vs. women who tested negative (n=30); and men who tested positive for HSV-2 (n=39) vs. men who tested negative (n=68)  Women  Men Variable  HSV-2 + N (%) HSV-2 - N (%) p-value   HSV-2 + N (%) HSV-2 - N (%) p-value  Tried to quit drugs past 6 months  35 (66%) 5 (63%) 0.99 14 (70%) 17 (50%) 0.15 Relapsed when trying to quit  past 6 months  14 (64%) 3 (60%) 0.99 7 (58%) 4 (25%) 0.12 Ever in methadone treatment  program  34 (40%) 6 (46%) 0.67 6 (19%) 7 (16%) 0.67 Currently in methadone treatment  program  24 (71%) 5 (83%) 0.99 4 (67%) 3 (43%) 0.59  ^restricted to participants who reported injection drug use in the past 6 months                      92 Table 4. 4: Model 1: Correlates of testing HSV-2 positive among the young women participating in the Cedar Project (n=106) Variable UOR 95% CI AOR 95% CI p-value Age 1.09 0.99-1.21 1.10 0.96-1.25 0.16 Location Vancouver  2.11 0.86-5.13 1.85 0.56-6.12 0.31 Mother attended residential school 2.70 1.03-7.08 2.52 0.90-7.09 0.08 Ever involved in survival sex 3.21 1.39-7.36 3.15 1.13-8.79 0.03 Heavy alcohol drinking  2.42 1.06-5.55 2.37 0.99-5.65 0.05 UOR: Unadjusted odds ratio from contingency tables  AOR: Adjusted odds ratio from multivariate regression analysis   Table 4. 5: Model 2: Correlates of testing HSV-2 positive among the young women participating in the Cedar Project (n=143) Variable UOR 95% CI AOR 95% CI p-value Age 1.09 0.99-1.21 1.05 0.94-1.17 0.41 Location Vancouver  2.11 0.86-5.13 1.70 0.65-4.48 0.28 Ever taken from biological parents  3.02 1.32-6.92 3.25 1.34-7.88 <0.01 Ever inject drugs 3.39 1.43-8.08 3.39 1.32-8.67 0.01 UOR: Unadjusted odds ratio from contingency tables  AOR: Adjusted odds ratio from multivariate regression analysis   Table 4. 6: Correlates of testing HSV-2 positive among the young men participating in the Cedar Project (n=98) Variable  UOR CI AOR CI p-value Age 1.10 1.01-1.22 1.05 0.95-1.16 0.33 Location Vancouver 2.09 0.93-4.65 1.47 0.61-3.53 0.99 Ever been in prison 3.25 1.30-8.08 2.99 1.11-8.07 0.03 Ever sexually abused 2.16 0.89-5.23 1.91 0.74-4.93 0.18 Culture played an important role in  developmental years 0.47 0.21-1.07 0.41 0.19-1.00 0.05 UOR: Unadjusted odds ratio from contingency tables  AOR: Adjusted odds ratio from multivariate regression analysis       93 4.4 Discussion This investigation of HSV-2 infection among a cohort of Indigenous young people who use drugs revealed a prevalence of 61%. As HSV-2 is a non-reportable disease, and is often asymptomatic, the true prevalence in Canada’s general population is unknown. However, Statistics Canada estimates it to be 13.6% (2011b). In British Columbia, over 2,500 positive cases of HSV-2 were reported by the BCCDC in 2006 alone (Li et al., 2008). National and provincial estimates do not report on Indigenous identity and exclude participants living on-reserve (Statistics Canada, 2013b). To our knowledge, only two Canadian studies have examined HSV-2 rates among Indigenous people. One study included 7,266 STI clinic attendees in Edmonton and Calgary where the overall HSV-2 prevalence was 19%. In that study, Indigenous clinic attendees were 2.6 times more likely to test positive than non-Indigenous attendees (Singh et al., 2005). The second study highlighted the disproportionate number of neonatal herpes infections among Indigenous newborns in Canada. The researchers actively solicited neonatal reports from all pediatricians across Canada from 2000-2003, and found Indigenous women represented 10.5% of all cases, despite comprising only 3.4% of the birthing population (Kropp et al., 2006).  In this study, the limited number of participants who were aware of their seropositive status prior to clinical testing raises concerns. Upon further examination of the data, the ten women who self-reported HSV-2 positivity were the same women who had self-reported ever having an outbreak. It is important to note that HSV-2 can shed even in the absence of an outbreak, and the virus can be transmitted during both oral and genital sex (Tronstein et al., 2011). While most HSV-2 infections do not lead to serious  94 physical complications, the virus is associated with ophthalmological ailments, encephalitis, aseptic meningitis, and vertical transmission that may result in neonatal injury or death (Center for Disease Control, 2015). STI diagnoses, particularly incurable ones such as HSV-2, can also have detrimental emotional, mental and psychological impacts, and severely interfere with personal relationships and one’s self-concept (Newton & McCabe, 2008).  The association between HSV-2 and HIV seroconversion The prevalence of HSV-2 within the Cedar Project cohort is especially concerning given the recognized association between HSV-2 infectivity and increased risk for HIV seroconversion. There are several biological mechanisms that facilitate the increased opportunity for HIV seroconversion due to HSV-2 infectivity. Genital ulceration caused by untreated STIs provides a portal of entry for HIV through mucosal disruption (Centers for Disease Control and Prevention, 1998); the presence of untreated STIs in the human body can lead to immunosuppression and increase susceptibility to acquiring new infections; and recurrent infections disrupt epithelial cells in the ulcerated region, recruiting activated CD4 cells that are targeted by HIV (Celum, 2004). As no Canadian study has examined the association between HSV-2 and HIV, we rely on international data to understand it. Among people who use non-injection drugs in the United States, a significant association was found between HSV-2 and HIV (AOR: 3.2 [95% CI: 2.3-4.5]) (Des Jarlais et al., 2010). In another US study among people who use injection drugs, this association was even higher (AOR: 7.9 [95% CI: 2.9-21.4]). These data yielded a population attributable risk of 71% for HSV-2 in the etiology of HIV infection (Des Jarlais et al., 2011). Two systematic reviews of longitudinal cohort  95 studies examined scenarios in which HSV-2 infection preceded HIV, and after adjusting for sexual behavior, the relative risk of contracting HIV due to HSV-2 was reported to be 3.1 [95% CI: 1.7-5.6] among women, 2.7 [95% CI: 1.9-3.9] among heterosexual men, and 1.8 [95% CI: 1.2-2.4] among men who have sex with men (Freeman et al., 2002; Wald et al., 2006). Another systematic review of 17,000 HIV cases and 73,000 controls from 1986-2006 reported the odds of the HIV/HSV-2 association to be 4.62 [95% CI: 2.85-7.47] among women (Chen et al., 2007b). In one study among 8,346 women in Uganda and Zimbabwe, HIV seroconversion was observed in 211 participants. The authors estimated that 42-65% of new HIV incidents could have been avoided if the participants had not been co-infected with HSV-2 (Brown et al., 2007).  HIV prevalence rates in Canada are generally low, however, they are reported to be as high as 20 times the national average (63.6/100,000) among people living on-reserve (CBC, 2015a). Yet, the association between high rates of HSV-2 and HIV infection remains unknown for Indigenous people, and HIV prevention efforts remain largely centered on parenteral transmission. While the presence of HSV-2 can increase risk for HIV seroconversion, treatment has not been found to mitigate this risk (Celum et al., 2008; Watson-Jones et al., 2008). As such, the most effective approach to interfering in the HSV-2/HIV pathway is to keep at-risk individuals seronegative. After that, sexual health services should help at-risk people learn how to identify herpetic ulcers, know when to seek treatment, and to refrain from sex during outbreaks. Early STI recognition and treatment can help circumvent HIV seroconversion, especially for asymptomatic infections (Fleming & Wesserheit, 1999; Orroth et al., 2003). To meaningfully support Indigenous people who use drugs, any such services should be developed within  96 culturally-safe and trauma-informed frameworks that account for the complex relationships between self-medication and sexual risk.  HSV-2 and the increased vulnerability of Indigenous women who use drugs In this study, women were 6.5 [95% CI: 3.74-1.53] times more likely to test positive for HSV-2 when compared to men. As previously mentioned, the rate of HSV-2 among Indigenous women in Canada is unknown. However, estimates from the general population reveal that women are 2.4 times more likely than men to be infected with HSV-2 in BC (Li et al., 2008). Nationally, Canadian women are 1.5 times more likely to test positive when compared to Canadian men (Statistics Canada, 2011b). Among people who use drugs in the United States, the prevalence of HSV-2 positivity is markedly higher among women (Des Jarlais et al., 2010; Hwang et al. 2000; Plitt et al., 2005).  Apart from the anatomical factors that increase susceptibility to contracting STIs among all women (Center for Disease Control, 2013), it is critical to emphasize that the reduced health status of Indigenous women who use drugs can be entirely attributed to historical and social barriers to health. If the prevalence of HSV-2 in this cohort is reported in isolation, it can reinforce negative stereotypes toward Indigenous women, discriminate against them, and perpetuate self-blame (Larkin et al., 2007; Health Canada, 1998). In order for such sexual health outcomes to be understood, they must be interpreted within the context of colonization and historical trauma.   The continued racialization and sexualizing of Indigenous women have been exacerbated by the ongoing social disparities that have diminished their traditionally safe, powerful, and autonomous positions in society (Oliver et al., 2015; Robinson, 2009). As a result, Indigenous women today are at extreme risk for poor sexual health outcomes due  97 to violence, sexual assault, poverty, inadequate food security, involvement in survival sex work, and self-medication (Callaghan et al., 2006; CBC, 2015b; Gesink et al., 2016; Healey et al., 2001; Macdonald, 2005; Milloy, 1999; van der Woerd et al., 2005; Walters et al., 2011; Young and Katz, 1998). The ways in which these lifetime vulnerabilities intersect with each other inform and affect the sexual wellbeing of Indigenous women who use drugs.  Access to and uptake of sexual health services is a challenge for many Indigenous women. Barriers to utilizing health resources that have been identified by researchers and Indigenous women (in Chapter 7) include: a shortage of female practitioners in many remote communities; the stigma of STIs; fear of disclosing sexual activity; lack of symptom recognition; and being subject to discrimination in the healthcare system (Goldenberg et al., 2008; Jackson & Reimer, 2008; Rusch et al., 2008b; Williams & Mohammed, 2009). To adequately support Indigenous women who use drugs, sexual, drug recovery, and mental health programs should incorporate gendered and culturally-safe approaches to care that address the underlying causes of negative sexual health outcomes. Indigenous researchers have identified multiple large-scale actions to support the sexual health of Indigenous women in Canada. These approaches have been summarized in Chapter 8.3. Familial fragmentation and increased sexual risk  The continued impacts of the legacies of the residential school and child welfare systems on the health of Indigenous young people was, regrettably, demonstrated in this study. In the adjusted analysis, women who had been taken away from their biological parents and who had a mother who attended residential school were respectively 3.25  98 [95% CI: 1.34-7.88] and 2.52 [95% CI: 0.90-7.09] times more likely to test positive for HSV-2. At baseline enrolment, 65% of all Cedar Project participants reported that they had been in the foster care system (Clarkson et al., 2015). The accumulation of risk-factors that are born of instability, displacement, detachment, and the traumas associated with being taken from one’s family places apprehended children in constant situations of vulnerability (Clarkson et al., 2015; Pearce, 2014). Cedar Project participants who have been in the child welfare system have shared the immense stress they experienced when they were torn from their families. They described how they ran away from foster homes, suffered from mental health illness, had difficulty building and maintaining relationships, and turned to self-medication to cope with their pain (Pearce, 2014). Having been apprehended as a child has also been independently associated with sexual abuse, HIV-positivity, homelessness, survival sex work (Clarkson et al., 2015), and reduced resilience (Pearce, 2014). This study’s findings therefore add to the body of work that demonstrates the immense health vulnerabilities of Indigenous young people who have been in foster care, such as their increased risk for HSV-2 infection.  Today, changes to child welfare policies have transferred the jurisdiction of child protection on-reserves to First Nations child and family service agencies. These agencies utilize Indigenous-based models that support families while keeping children connected to their communities and culture (Simard, 2009). Unfortunately, they are limited in number and unable to meet demands, as they receive minimal funding and cannot serve Indigenous families who live off-reserve (Blackstock & Trocmé, 2004). In order to protect Indigenous children, Indigenous leaders demand that the underlying causes of child apprehension, which are rooted in colonization, self-medication, and reduced self- 99 determination, be urgently addressed (Christian, 2010). To that end, in place of removing Indigenous children from their families, it is critical to boost the financial and social capital available to Indigenous community-based agencies that provide care to families who are struggling with poverty, substance dependence, and intergenerational trauma. This would enable service providers to invest in substantive cultural interventions for collective healing, improve short- and long-term health outcomes, and break the cycles of intergenerational trauma (Blackstock & Trocmé, 2004; Frohlich et al., 2006; Tousignant & Sioui, 2009; Ungar, 2008).  Drug and alcohol use and HSV-2 positivity In this study, women who tested seropositive for HSV-2 were 3.39 [95% CI: 1.32-8.67] and 2.37 [95% CI: 0.99-5.65] times more likely to inject drugs and drink alcohol heavily, respectively. For Indigenous young people who have experienced childhood maltreatment and violence, using drugs and alcohol is a means of coping with stress, anxiety, and pain (Gesink et al., 2016; Keyes et al., 2012; McEvoy and Daniluk, 1995; Pearce, 2014). Many Indigenous young people who use drugs recognize that substance dependence is a symptom of profound trauma (Pearce, 2014). They attribute such dependence to cultural losses, the loss of family and community members who had shortened lives (Whitbeck et al., 2009), extreme violence (Gesink et al., 2016; Pearce, 2014), and fragmented families (Pearce, 2014; Wexler et al., 2014).  As previously noted, no known study to date has examined the prevalence or risk factors for HSV-2 among Indigenous people who use drugs in Canada. In the United States, HSV-2 prevalence among people who use drugs is significantly higher than that of the general population, ranging from 22-53% among men and 59%-85% among women  100 (Des Jarlais et al., 2010; Plitt et al., 2005). The independent association between injection drug use and HSV-2 seropositivity among women in this cohort is alarming, as Indigenous women who use drugs have been found 1.98 [95% CI: 1.06–3.72] times more likely to transition to injection drug use when compared to Indigenous men who use drugs (Miller at al., 2011). Drug use increases risk for contracting STIs through the exchange of sex for drugs or money, having multiple sex partners, and/or having sex with partners who use injection drugs (Booth et al., 2000; Irwin et al., 1996). From survey data, researchers have demonstrated a correlation between frequent substance use and unsafe sex among Indigenous young people who use drugs (Anderson, 2002; Devries, Free, & Jategaonker, 2007; First Nations Information Governance Committee, 2012; Kotchick et al., 2002). In provincial surveys, between 17-26% of sexually active Indigenous young people have reported being “drunk or high” during sex (Anderson, 2002; Tsuruda et al., 2013). Among Indigenous young women, substance use is an independent risk factor for both pregnancy and an STI diagnosis (Devries et al., 2009a). Young women who use drugs are particularly at-risk of experiencing negative health outcomes, as the intersections of race, social class, and gender are intensified by the sexual risks associated with self-medication (Baldwin et al., 2000; Craib et al., 2003; Schneider et al., 2012). It is clear that increased substance dependence among Indigenous communities (Walls et al., 2013) has immediate and dire consequences for sexual health, including contracting HSV-2. Indigenous scholars emphasize that Indigenous young people who use drugs do so to cope with ongoing trauma (Walters & Simoni, 2002). While culturally-safe and trauma-informed interventions that address the link between substance  101 dependence and STI risk can support sexual health (Chersich & Rees, 2010; Schneider et al., 2012), it is critical to couple such programs with mental health services. Without addressing the root causes of self-medication, the sexual health risks of Indigenous young people who are living with unresolved pain cannot truly be mitigated. The integration of services that are built upon Indigenous models of care and which incorporate strengths-based approaches can help expand care delivery to provide accessible, realistic, and relevant treatment and prevention options. HSV-2 risk among Indigenous women who use drugs and who are involved in survival sex work In this study, despite higher self-reported condom use consistency with casual sex partners and clients, a significant association between survival sex work and HSV-2 positivity was found (AOR: 3.15 [95% CI: 1.13-8.79]). While there is no Canadian data to draw from, researchers in the United States have demonstrated a similar association in the general population of people who use drugs. Plitt et al. (2005) reported HSV-2 infection to be 3.2 [95% CI: 1.2-8.6] times higher among women who engage in survival sex work. Hwang et al. (2000) demonstrated the prevalence of HSV-2 positivity among women who use drugs and who engage in survival sex work to be 74% (vs. 41%. among women who use drugs but do not engage in survival sex work).  Although social desirability bias may be influencing self-reported data, this study’s findings may suggest that the risk of contracting STIs among women involved in survival sex work is largely driven by injection drug use and heavy alcohol consumption, both of which are associated with inconsistent condom use (Devries, Free, & Jategaonker, 2007; First Nations Information Governance Committee, 2012). It is also  102 important to consider the role of crack smoking on condom use consistency. Smoking crack was correlated with injection drug use, heavy alcohol drinking, and survival sex work, it was therefore deemed not appropriate for inclusion in the multivariate models as it may have diminished the significance of other important associations. However, studies among people who use drugs in the United States have demonstrated significantly higher HSV-2 prevalence among people who use crack when compared to people who use other drugs (Hwang et al., 2000; Ross et al., 1999; Ross et al., 2002). Among Indigenous women who use drugs, crack use has been associated with unsafe sex (Chavoshi et al., 2012; Duff et al., 2013; Mehrabadi et al., 2008a) and survival sex work (Chettier et al., 2010). It is critical that resources designed to support young Indigenous women who are involved in survival sex work focus their efforts on harm reduction and drug recovery, as the intent and ability to consistently use condoms is not always possible in the presence of drug and alcohol use.  Vulnerability of incarcerated men  In this study, having ever been in prison was significantly associated with HSV-2 seropositivity in adjusted analysis among men (AOR: 2.99 [95% CI: 1.11- 8.07]). Plitt et al. (2005) demonstrated a similar finding in a cohort of men who use drugs and who had ever been incarcerated (AOR: 2.7 [95% CI: 1.1-6.6]). While the temporal sequence of infection cannot be determined in this study, the strengthening of culturally-safe sexual health resources both within and outside of prison before, during, and after incarceration is important. Such resources can help inmates learn when to seek testing, treatment, and how to take preventive measures. Current guidelines in correctional facilities stipulate that HSV-2 testing will only be provided if inmates present symptoms (Public Health  103 Agency of Canada, 2013). Given the findings of this study, the disproportionate number of Indigenous men who are incarcerated, the asymptomatic and highly infectious nature of HSV-2, and the increased risk of acquiring HIV due to HSV-2 (Freeman et al., 2002, Wald et al., 2006), it is highly recommended that HSV-2 testing be incorporated into routine STI screening in prison. Culture as protection  In this study, the protective effect of traditional culture on sexual health was demonstrated. Among men, those who reported that culture played an important role during their developmental years were significantly less likely to test positive for HSV-2 (AOR: 0.41 [95% CI: 0.19-1.00]). The buffering impacts of Indigenous traditions, languages, and spirituality has been demonstrated across a multitude of Indigenous populations in North America (Andersson & Ledogar, 2008; Chandler & LaLonde, 1998; Clark et al., 2013; Currie et al., 2013; McIntyre et al., 2001; Pearce, 2014; Torres Stone et al., 2006). Participation in traditional activities among Indigenous young people has been associated with alcohol cessation and decreased criminal activity (Andersson & Ledogar, 2008) − two factors that were found independently associated with HSV-2 seropositivity in this study. In Canada, Indigenous culture and traditions have been identified as healing “medicines” that mitigate STI risks among Indigenous women who have experienced sexual abuse (Gesink et al., 2016). Cultural connectedness is tied to strong school and community involvement among Indigenous young people (Tourand et al., 2016), both of which reduce the likelihood of engaging in unsafe sex (Devries et al., 2009a, Tourand et al., 2016). Cultural connectedness has also been shown to reduce stress (McIntyre et al., 2001) and increase resilience (Pearce, 2014), which mitigates against substance use, and  104 consequently, negative sexual health outcomes (Tourand et al., 2016). Despite heterogeneity across Indigenous Nations, the overarching traditional beliefs around sex in Indigenous culture are healthy. Indigenous health frameworks view sex as a sacred gift (Kliest, 2008; Newhouse, 1998) and shun sexual violence (Bopp & Bopp, 1997, p. 8). Prior to European contact, matters of sexuality were openly discussed, expressed, and accepted as a natural and vital component of development (Aboriginal Nurses Association, 2002; McGeough, 2008; Newhouse, 1998). Indigenous young people were initiated into adulthood with coming-of-age ceremonies that supported their physical, psychological, and emotional transformations. Such traditions facilitated a positive sense of identity and transmitted lessons on egalitarianism, the sacredness of sex, its connection to spirituality, and how to create meaningful relationships (Markstrom, 2008). This study’s finding demonstrates that these valuable beliefs continue to shield against negative sexual health outcomes, even in the face of lifetime adversity.   Unfortunately, many Indigenous young people are not accessing their culture due to the interruption of the intergenerational transmission of traditional ways. Many who live in urban dwellings and/or are disconnected from their communities are unable to benefit from its positive health impacts (Fleming & Ledogar, 2008; Goodkind et al., 2012). Given the association between child apprehension and poor sexual health outcomes, and the protective effect of culture on sexual wellbeing observed in this study, service providers should support Indigenous young people who have been taken from their families and reconnect them with their communities and culture. Sexual health programs that integrate cultural interventions can help facilitate healing, instill self-care practices, strengthen identities, and reinstate traditional values that support positive  105 sexual health outcomes (Brant Castellano, 2008; Kliest, 2008; Newhouse, 1998; Oliver et al., 2015). Limitations and conclusions  The limitations of this study must be acknowledged. First, only data for participants who returned for a follow-up interview were included, and potentially crucial information from participants who were lost to follow-up may have been missed. Second, as the focus of this study was restricted to Indigenous young people who use drugs, it cannot be generalized to all Indigenous people in Canada. Third, the Cedar Project has a non-random recruitment methodology, which may not capture the most vulnerable members of society. However, the connectedness of the recruitment team with the community as well as its rigourous recruitment methods and eligibility criteria give us confidence that the study has a representative sample of Indigenous young people who use drugs in BC. Lastly, this study largely relied on self-reported data. Therefore, it cannot account for social desirability or recall bias, especially for events that occurred during early childhood, or while under the influence of drugs.  To our knowledge, this is the first study that has examined the prevalence and correlates of HSV-2 seropositivity among Indigenous young people who use drugs in Canada. While the direct and indirect impact of drug use on increased risk for STI acquisition is well known, this study sheds light on how such risks are compounded for Indigenous people who experience them together with historical trauma and social marginalization. These findings suggest that the ongoing impacts of colonization and self-medication are exacerbating the risk for contracting HSV-2 among Indigenous young people who use drugs. Cultural interventions built upon Indigenous wellness frameworks  106 can help Indigenous young people who face adversities achieve emotional, spiritual, physical, and psychological balance, and consequently, experience improved sexual health outcomes. This is especially true for Indigenous people who have been in foster care, been incarcerated, and/or use drugs/alcohol to cope with unresolved trauma. If interventions are developed meaningfully and involve the very young people they aim to serve, they can provide alternate strategies for healing and support sexual wellbeing.                   107 Chapter 5: The prevalence and correlates of syphilis positivity among Indigenous young people who use drugs in British Columbia  5.1 Introduction STIs are considered to be effective biomarkers for sexual vulnerability (Gallo et al., 2013; Weller & Davis, 2005). Syphilis in particular has detrimental consequences if left untreated (Center for Disease Control, 2014), and can increase susceptibility to acquiring HIV (Chesson & Pinkerton, 2000; Taha et al., 1998). The Annual Summary of Reportable Diseases in British Columbia (2013) identified that between 2004 and 2013, First Nations people accounted for 9.1% (n=277) of newly reported syphilis cases, despite comprising only 5% of the provincial population (BCCDC, 2013). This estimate did not include data on Inuit, Métis, or people living on-reserve. As such, an accurate estimation of syphilis prevalence among Indigenous people in BC is unknown.  While the annual representation of Indigenous people among newly reported syphilis cases in BC declined from 2005 to 2010, it has started to increase once again (BCCDC, 2013). Since 2010, surveillance data from syphilis outbreaks in the Western provinces of Canada report that a disproportionate number of cases have occurred among Indigenous people (CBC, 2010; CBC, 2015a; Government of Alberta, 2010; Ogilvie et al., 2009). Wylie and Jolly (2001) suggest that many Indigenous communities have tightly-knit sexual networks where STIs can spread rapidly, which can be detrimental to the sexual wellbeing of communities. Such health disparities are unacceptable, and speak to what Indigenous scholars, leaders, and experts have contended for years: the legacies of colonization continue to subject vulnerable Indigenous young people to sexual health risks. Indigenous scholars stress that any investigation of such disparities must shift away  108 from individual behaviours and focus on historical contexts they are situated within (Christian & Spittal, 2008; Duran & Walters, 2004; Vernon, 2001; Walters et al., 2011) The paucity of information on the sexual health of Indigenous young people who use drugs in Canada led to the development of this study. Sexual vulnerability was investigated by quantifying the prevalence of syphilis and establishing the risk factors associated with syphilis positivity among 250 young Indigenous men and women who participated in the Cedar Project: an Indigenous-governed initiative addressing the health risks of Indigenous young people who use injection and non-injection drugs in BC. This investigation locates risk factors associated with sexual vulnerability within a framework of intergenerational trauma. Further, the study will help identify participants who are most at-risk for sexual vulnerability within a cohort of Indigenous young people who continue to demonstrate resilience in the face of ongoing pain, historical trauma, and social marginalization. 5.2 Methods  5.2.1 The Cedar Project study design The Cedar Project is an ongoing prospective cohort study of Indigenous men and women who use injection and non-injection drugs in three Canadian cities. This study includes all data from the 250 participants who completed the 16th and 17th rounds of routine follow-up questionnaires. The Cedar Project’s enrollment eligibility criteria stipulate that participants be of self-reported Indigenous ancestry, be between the ages of 14 and 30 at the time of study enrolment, and have used illicit drugs one month prior to enrolment. Please refer to Chapter 3.2 for complete details on the Cedar Project’s recruitment strategies, eligibility criteria, questionnaires, study methods, and description  109 of variables.    5.2.2 Data collection  During Cedar Project follow-up interviews conducted from December 2012 to October 2013, Cedar Project staff invited actively enrolled participants to partake in this study. Participants were informed that they could provide an added blood sample to test for syphilis during routine sample collection for HIV and Hepatitis C testing. The Cedar Project provided its customary $25 honorarium during routine follow-up interviews, and an additional $10 honorarium for participation in this study. All the young men and women who were extended the invitation to participate, accepted.  As with HIV and HCV testing, participants received counseling from Cedar Project nurses prior to testing and after the results were received. The College of Registered Nurses of British Columbia provided Cedar Project staff with guidelines and training materials pertaining to syphilis treatment and counseling. Before signing the consent form, participants were advised that a seropositive test would result in notification to the Provincial Health Services Authority (PHSA) and antibiotics would be prescribed to treat any cases of active or untreated syphilis as necessary. Participants were informed that their partners would require notification for testing and treatment. No participants withdrew their agreement to partake in this study upon receiving this information. Informed consent was obtained from the 250 men and women who volunteered to participate.  All test tubes were marked with the study number of each participant. Blood samples were refrigerated and stored in locked offices before being shipped for testing to the BCCDC High Volume Serology Program in the Central Processing & Receiving  110 Laboratory. Syphilis testing was conducted using the Treponema pallidum particle agglutination (TPPA) test. The TPPA has 85-100% sensitivity and 98-100% specificity to detect primary syphilis, and 98-100% sensitivity for secondary, latent, or tertiary syphilis (Creegan et al., 2007). Indeterminate TPPA results were tested for recombinant antibodies with the LIA assay. Positive TPPA results were tested with rapid plasma regain (RPR) to determine past or active infection. Samples were destroyed immediately after clinical testing was completed. All positive syphilis reports were sent to the BCCDC STI/HIV Division by the PHSA Laboratory, entered into the surveillance system, and reviewed by the clinic physician and/or Registered Nurse (RN) for diagnosis, treatment recommendations, and partner follow-up. The Cedar Project received copies of all syphilis test results. Only 1 of the 21 positive syphilis cases required treatment (as determined by the reviewing BCCDC clinic physician). The BCCDC contacted Cedar Project nurses to discuss follow-up procedures. Cedar Project nurses relayed clinical results to study participants in person and ensured that all those who tested positive either received treatment or had previously completed treatment. Treatment could be administered through the Cedar Project or referred to the BCCDC STI outreach team in Vancouver. Cedar Project nurses counseled all participants who tested positive regarding partner notification.  Please refer to Chapter 3.1 for detailed information on the Cedar Project’s ethics protocols, confidentiality agreements, and commitment to participant follow-up and care.  5.2.3 Statistical analysis  Prevalence of a history of syphilis infection and corresponding 95% confidence intervals were calculated for all study participants. Data from the Cedar Project  111 Demographic and Nursing follow-up questionnaires that participants provided blood samples in were linked to their test results to investigate variables associated with syphilis positivity. Detailed descriptions for study variables are available in Chapter 3.2.3.  Of the 250 participants who provided blood samples, a history of infection with the syphilis bacterium (Treponema pallidum) was found among 21 participants. Women who were living in Vancouver comprised 95% of all positive cases (n=20). In order to draw meaningful comparisons with participants who tested seronegative, the analysis of risk factors related to syphilis was restricted by gender (women) and location (Vancouver).  Bivariate analyses assessed differences in demographic characteristics, drug use patterns, and sexual vulnerabilities between participants who had a history of syphilis infection to those who did not. Categorical data were explored using Pearson’s chi-squared tests. Fisher’s exact test was used when 25% or more of the expected cell frequencies in a contingency table were less than 5. Means and standard deviations were calculated for continuous variables (e.g. age at enrolment). Student’s t-test was used for comparing the means of different groups. Medians and ranges were calculated for non-normally distributed variables. The Wilcoxon rank sum test was used for comparing the medians of different groups.  Unadjusted odds ratios were calculated for all covariates and presented at 95% confidence intervals. Odds ratios were not calculated when 25% or more of the expected cell frequencies in a contingency table were less than 1 (denoted as “N/A” in Tables 5.1-5.3). Given the sample size and the proportion of participants who tested positive for  112 syphilis, it was not appropriate to conduct multivariate modeling (Peduzzi et al., 1996). However, by restricting bivariate analyses to only women in Vancouver, two potential confounders (gender and location) were controlled for. All statistical analyses were performed on SPSS software, version 22.   5.3 Findings Among the 250 participants who were tested, 143 (57%) were women, of whom, 58 (41%) lived in Vancouver. A history of syphilis was found among 21 participants (8% [95% CI: 5%-11%]), 20 of whom were women living in Vancouver. One woman had active syphilis and was followed up by Cedar Project nurses for treatment. The remaining participants had previously completed treatment (confirmed by Cedar staff).  Tables 5.1-5.3 compare demographic characteristics, behavioural, drug use, and other putative risk factors for all women living in Vancouver who tested positive for syphilis (n=20) versus women who did not (n=38). Of the 20 women who tested positive, only 9 (45%) self-reported ever having syphilis (Table 5.2). Among women who tested positive for a history of syphilis infection, 95% tested positive for HSV-2, 25% were HIV+, and 40% were HCV+ (Table 5.2).  In bivariate analyses, a history of syphilis was significantly associated with experiencing violence in the past six months (43% vs. 4%; p<0.01) (Table 5.1), having binged on non-injection drugs in the past six months (82% vs. 31%; p=0.02); injecting drugs in the past six months (75% vs. 18%; p<0.01); and currently being in a methadone treatment program (100% vs. 53%; p<0.01) (Table 5.3). Marginally significant associations with syphilis positivity included having a mother who attended residential  113 school (69% vs. 36%; p=0.09) and smoking heroin in the past 6 months (46% vs. 10%, p=0.07).  Women who tested negative for syphilis were significantly more likely to self-report ever having a chlamydial infection (61% vs. 25%; p=0.01) (Table 5.2).                      114 Table 5. 1: Comparison of demographic and traumatic life events among women living in Vancouver with a history of syphilis (n=20) vs. women without (n=38)  Odds ratio of “N/A” denotes one or more cells <1       Variable  Syphilis + N (%) Syphilis - N (%) p-value  Odds Ratio  (95% CI) Mean age (SD) 23.8 (3.21) 22.5 (4.33) 0.11 1.03 (0.84-1.12) Sexual identity LGBTQ 3 (15%) 4 (11%) 0.68 1.50 (0.30-7.48) Father attended residential school 6 (60%) 8 (36%) 0.27 2.63 (0.57-12.18) Mother attended residential school 9 (69%) 9 (36%) 0.09 4.00 (0.95-16.77) Ever taken from biological parents  12 (60%) 30 (79%) 0.13 0.40 (0.23-2.31) Relationship status not single 6 (43%) 9 (41%) 0.91 1.25 (0.33-4.79) Ever on streets for >3 nights  15 (75%) 28 (74%) 0.91 1.07 (0.31-3.71) Ever on streets for >3 nights past 6 months 5 (36%) 3 (13%) 0.12 3.89 (0.76-19.86) Ever been in prison  12 (100%) 26 (93%) 0.99 N/A Ever attempt suicide 7 (78%) 11 (61%) 0.67 2.23 (0.35-13.96) Ever diagnosed mental illness 3 (15%) 11 (31%) 0.33 0.40 (0.09-1.66) Ever received counseling 5 (42%) 12 (50%) 0.64 0.71 (0.18-2.89) Counseling past 6 months 3 (21%) 3 (13%) 0.65 1.91 (0.33-11.08) Ever been denied services due to drug use  4 (20%) 8 (22%) 0.99 0.88 (0.22-3.37) Ever been denied shelter due to drug use  6 (32%) 7 (19%) 0.29 1.98 (0.56-7.04) Experienced violence past 6 months 6 (43%) 1 (4%) <0.01 17.25 (1.79-166.09) Did not graduate high school 16 (80%) 29 (78%) 0.99 1.10 (0.29 - 4.24) Participated in Traditional ceremonies  past 6 months  4 (29%) 1 (4%) 0.05 9.2 (0.91-93.03) Culture/Tradition played important role in  development 9 (57%) 9 (38%) 0.27 3.0 (0.76-11.81)  115 Table 5. 2: Comparison of sexual vulnerabilities among women living in Vancouver with a history of syphilis (n=20) vs. women without (n=38) Variable  Syphilis + N (%) Syphilis - N (%) p-value  Odds Ratio  (95% CI) Median age of first willing sex (range) 15 (11-20) 15 (10-22) 0.83 0.97 (0.78-1.12) Median age of first sexual abuse (range) 6 (2-18) 5 (1-15) 0.69 1.06 (0.91-1.24) Ever sexually abused 12 (60%) 23 (62%) 0.87 0.91 (0.29-2.78) Sexually abused past 6 months  2 (14%) 0 (0%) 0.13 N/A Ever involved in survival sex 16 (80%) 23 (61%) 0.16 2.61 (0.73-9.33) Survival sex past 6 months 7 (54%) 5 (29%) 0.18 2.8 (0.61-12.66) Ever been pregnant  17 (85%) 25 (68%) 0.14 2.72 (0.67-11.11) Pregnant in last 6 months  0 (0%) 4 (18%) 0.14 0.32 (0.03-3.21) Ever had an abortion 13 (77%) 13 (50%) 0.12 3.25 (0.84-12.65) Abortion since last visit 1 (11%) 4 (19%) 0.63 N/A Condom use for insertive sex with regular  partner* 2 (25%) 2 (14%) 0.60 2. 0 (0.22-17.89) Regular sex partner uses injection drugs * 1 (12.5%) 2 (14%) 0.99 0.86 (0.07-11.26) Regular sex partner HIV+* 1 (13%) 1 (7%) 0.99 1.86 (0.10-34.44) Casual sex partner HIV+* (2 unsure) 2 (9%) 0 (0%) 0.99 0.86 (0.04-16.85) Condom use for insertive sex with casual  partner ** 3 (75%) 4 (100%) 0.99 N/A Casual sex partner uses injection drugs ** 1 (6%) 0 (0%) 0.99 N/A Condom use for insertive sex with clients *** 4 (100%) 4 (100%) N/A N/A Offered money not use condom*** 11 (79%) 15 (88%) 0.64 0.49 (0.07-3.44) Accepted money to not use condom *** 4 (36%) 6 (40%) 0.99 0.86 (0.17-4.27) Use drugs with clients 6 (86%) 4 (80%) 0.99 1.50 (0.07-31.57) Ever had a bad date 3 (43%) 0 (0%) 0.24 N/A Ever had STI (self-reported) 13 (65%) 30 (79%) 0.25 0.49 (0.15-1.65) Had an STI in the past 6 months 1 (8%) 3 (16%) 0.63 0.44 (0.04-4.82) Ever treated for STI 13 (65%) 27 (71%) 0.30 0.55 (0.16-1.85) Ever had an outbreak 1 (50%) 2 (100%) 0.19 N/A Outbreak in the past 6 months 0 (0%) 1 (50%) 0.31 N/A   116 Table 5. 2 (continued): Comparison of sexual vulnerabilities among women living in Vancouver with a history of syphilis (n=20) vs. women without (n=38) Variable  Syphilis + N (%) Syphilis - N (%) p-value  Odds Ratio  (95% CI) Self-reported chlamydia  5 (25%) 23 (61%) 0.01 0.22 (0.07-0.72) Self-reported gonorrhea   4 (20%) 9 (24%) 0.99 0.81 (0.21-3.04) Self-reported syphilis  9 (45%) 3 (8%) <0.01 9.55 (2.19-41.59) Self-reported HSV-2  3 (15%) 6 (16%) 0.99 0.94 (0.21-4.24) HSV-2 + 19 (95%) 31 (82%) 0.24 4.29 (0.49-37.64) HIV+ 5 (25%) 8 (21%) 0.73 1.25 (0.35-4.49) HCV+ 8 (40%) 17 (45%) 0.73 0.82 (0.27-2.47) Pap smear in the past 6 months 14 (100%) 22 (100%) N/A N/A Abnormal pap 3 (21%) 1 (5%) 0.28 5.72 (0.53-61.75) Regular pap smears 12 (86%) 16 (73%) 0.44 2.25 (0.38-13.16) On birth control 11 (79%) 12 (55%) 0.18 3.06 (0.66-14.08)  *    Restricted to participants who reported having regular sex partners  **  Restricted to participants who reported having casual sex partners  ***Restricted to participants who reported having clients  Odds ratio of “N/A” denotes one or more cells <1                117 Table 5. 3: Comparison of drug related vulnerabilities among women living in Vancouver with a history of syphilis (n=20) vs. women without (n=38) Variable  Syphilis + N (%) Syphilis - N (%) p-value  Odds Ratio  (95% CI) Ever overdose 7 (37%) 6 (16%) 0.08 3.01 (0.84-10.82) Heavy Alcohol Drinking 16 (80%) 29 (76%) 0.99 1.24 (0.33-4.68) Blackout past 6 months 4 (50%) 6 (67%) 0.64 0.50 (0.07-3.55) Non-injection drugs past 6 months 11 (79%) 19 (79%) 0.99 0.96 (0.19-4.84) Crack smoking past 6 months 11 (100%) 16 (80%) 0.27 N/A Cocaine smoking past 6 months 3 (27%) 5 (25%) 0.99 1.13 (0.21-5.97) Crystal smoking past 6 months 3 (27%) 5 (25%) 0.99 1.13 (0.21-5.97) Heroin smoking past 6 months 5 (46%) 2 (10%) 0.07 7.5 (1.14-49.26) Binge non-injection drug use past 6 months  9 (82%) 3 (31%) 0.02  9.90 (1.54-63.69) Ever inject drugs 13 (65%) 20 (53%) 0.37 1.67 (0.55-5.11) Inject drugs past 6 months 9 (75%) 3 (18%) <0.01 14.0 (2.29-85.22) IV crystal past 6 months^ 1 (25%) 4 (29%) 0.99 0.44 (0.07-10.59) IV cocaine past 6 months^ 1 (25%) 6 (43%) 0.99 0.44 (0.04-5.41) IV heroin past 6 months^ 3 (75%) 10 (71%) 0.99 1.2 (0.09-15.26) Ever need help injecting^ 7 (64%) 11 (65%) 0.99 0.95 (0.19-4.64) Ever use INSITE 3 (75%) 11 (85%) 0.99 0.55 (0.04-8.27) Drug or alcohol treatment past 6 months 9 (64%) 9 (39%) 0.14 2.80 (0.71-11.09) Tried to quit drugs past 6 months  11 (79%) 17 (71%) 0.72 1.51 (0.32-7.12) Ever in methadone treatment program  10 (71%) 15 (63%) 0.73 1.50 (0.36-6.23) Currently in methadone treatment program  10 (100%) 8 (53%) 0.02 N/A  ^ restricted to those participants who reported injection drug use in the past 6 months  Odds ratio of “N/A” denotes one or more cells <1           118 5.4 Discussion Syphilis and the increased vulnerability of Indigenous women who use drugs This examination of STI vulnerability among 250 Indigenous young people who use drugs in British Columbia found that 8.4% of all participants had become infected with syphilis during their life. The substantial overrepresentation of Indigenous women who use drugs among positive syphilis cases speaks to their immense vulnerability to negative sexual health outcomes. Provincial data have demonstrated the disproportionate representation of Indigenous women among people who have acquired syphilis in BC as well. From 2004-2013, Indigenous women accounted for only 5% of all women in the province, but comprised over one quarter of all syphilis cases among women in BC. While only 11% of syphilis cases in the non-Indigenous population occurred among women, Indigenous women accounted for 43% of all syphilis infections among all Indigenous people (BCCDC, 2013). Data from a 2009 syphilis outbreak in Alberta reported the majority of cases occurred among non-Indigenous men in the general population. However, when the rate of infection was calculated, Indigenous women were 20.5 times more likely than non-Indigenous men to have been affected (Government of Alberta, 2010). In BC, Indigenous women comprised less than half of all syphilis cases among Indigenous people from 2004-2013 (BCCDC, 2013). In this study, 95% of cases occurred among women. In order to understand such disparities, it is critical to discuss them in the context of the historical traumas that impact sexual wellbeing. The compromised health status of Indigenous women is not a new phenomenon; it is a direct product of colonization (Native Women’s Association of Canada, 2010). Prior to European contact, Indigenous women often held equal power to men in society, and in some cases, lived in  119 matriarchies. While heterogeneity does exist across Indigenous tribes and Nations, on the whole, women were venerated as the givers of life and bearers of tradition. Indigenous women practiced rightful autonomy over their bodies and sexuality. These social dynamics stood in stark contrast to the European doctrine of male dominance. The legislations that aimed to eradicate Indigenous ways of living were not only influenced by colonial beliefs that Indigenous people were racially inferior, but also by sexist ideologies that deemed women to be subordinate to men. The colonizers attempted to diminish the social status of Indigenous women by way of cultural genocide, objectification, and familial fragmentation through the residential school and child welfare systems (Oliver et al., 2015; Robinson, 2009).  As a result of these historical injustices, Indigenous women in Canada are subjected to poverty, high rates of violence, and abuse (CBC, 2015b; Callaghan et al., 2006; Gesink et al., 2016; Macdonald, 2005; Milloy, 1999; Stout, Kipling & Stout, 2001; van der Woerd et al., 2005; Yee, Apale & Deleary, 2011). In this study, women who tested positive for syphilis were more likely to report having experienced recent violence. While all Canadian women face higher risk of experiencing sexual violence when compared to men (Libby et al., 2005), this risk is substantially higher among Indigenous women (Amnesty International, 2014; Evans- Campbell et al., 2006). Indigenous women who are in abusive relationships are particularly vulnerable to contracting STIs, as they are more likely to have unsafe sex when compared to non-Indigenous women (Devries et al., 2008; Saewyc et al., 2006; Simoni, Seghal, & Walters, 2004). Unfortunately, many sexual health programs are designed to only address the dynamics of consensual encounters and fail to consider the complex psychological effects of abusive relationships  120 on the ability to demand condom use and self-protect against STIs (Craib et al., 2003; Muldoon et al., 2015).  The historical and lifetime disparities that impact the sexual vulnerability of Indigenous women who use drugs are accompanied by a general biological vulnerability to STI acquisition among females. The thin and delicate lining of the vagina is highly susceptible to viral and bacterial infections, and the moisture in female genitalia provides an ideal environment for bacteria to grow (Center for Disease Control, 2013). Many STIs are asymptomatic, or present with symptoms that are difficult to identify. Cases of primary syphilis may easily be missed because they do not cause vaginal pain, which can delay treatment (Center for Disease Control, 2013). As explained by the young women who participated in the in-depth interviews in Chapter 6, lack of symptom recognition is also due to the presence of ulcers and skin infections caused by injection drug use in the upper thigh area.   As the mediating factors that heighten vulnerability to negative sexual outcomes among Indigenous women are rooted in colonization, culturally-safe, trauma-informed health outreach programs that address the legacies of the residential school and child welfare systems are necessary. These programs should back Indigenous women’s self-determination and self-sufficiency in order to best support their sexual health. The integration of Indigenous traditions and wellness frameworks into gender-specific programs can help intervene in the pathways of risk to contracting ulcerative STIs, such as syphilis (Native Women’s Association of Canada, 2010). These strategies have been described in Chapters 7.4 and 8.3.   121 STI risks and drug use  In this study, injecting drugs was significantly associated with a history of syphilis. Transition to injection drug use has been independently associated with a 4.6-fold increase in the risk of syphilis infection among people who use drugs in the United States - even after controlling for age, sex, race, and survival sex work (Lopez-Zetina et al., 2000). This is concerning, as Indigenous young people who face adversities and use drugs do so as a coping strategy to disconnect from their lived traumas (Walters & Simoni, 2002). When drugs are used with this intent, injection can quickly become the preferred mode of administration, as disassociation from pain occurs more quickly and effectively. For individuals living with such pain, managing emotional suffering may take precedence over taking steps to avoid contracting infectious diseases (Pearce, 2014). Syphilis positivity was also associated with binging on non-injection drugs, smoking heroin, and being in methadone maintenance treatment (MMT). While opioids such as heroin may suppress sexual desires, they can still profoundly impact sexual health, as a person in withdrawal may be more likely to exchange unprotected sex for drugs, or be suffering from the pain of dope-sickness, which can interfere with the ability to prioritize condom use (Bryan et al., 2000). Such vulnerabilities were confirmed by the young women who were interviewed in Chapter 6. Upon closer examination of this study’s data, the young women who reported heroin use were those receiving MMT. The women in this study may be accessing methadone not to stay off drugs, but instead, to control withdrawal symptoms and decrease the risk of experiencing violence during dope-sickness (Spittal, 2008). Nonetheless, MMT has been associated with reduced high-risk sexual behaviours (Iguchi, 1998; Sees et al., 2000; Sorenson & Copland, 2000; Wells  122 et al., 1996). Unfortunately, Indigenous people are inadequately accessing MMT due to a lack of culturally-safe programming, the prevalence of abstinence-based treatments, and/or the fear of having their children apprehended (Benoit et al., 2003; Canadian Aboriginal AIDS Network, 2004; Kerr et al., 2005; Methadone Strategy Working Group, 2004; Poole & Trainor, 2000).  It is worth mentioning that all women who tested positive for syphilis in this study and who used non-injection drugs, reported smoking crack. The established literature demonstrates that crack use increases high-risk sexual behaviours. These include having sex partners who inject drugs, exchanging sex for drugs or money, using drugs during sex, having multiple sex partners, and not using condoms consistently (Booth et al., 2000; Booth et al., 2007; Chavoshi et al., 2012; Irwin et al., 1996; Shannon et al., 2007; Shannon et al., 2008). Syphilis positivity has been reported to be as high as 13% among people who use crack in the general population in the United States (Ross et al., 1999). People who use crack have also been found three times more likely to test positive for syphilis when compared to individuals who use other drugs (Ross et al., 2006).  In the Cedar Project, Indigenous women who use drugs are particularly vulnerable to such harms, as crack use is independently associated with survival sex work (AOR: AOR:2.9 [95% CI: 1.6, 5.2]) (Mehrabadi et al., 2008a). Treatment for crack cocaine can reduce the sexual risks associated with crack use (Wimberly et al., 2016), but accessing treatment continues to be impeded by systemic discrimination and the lack of meaningful drug treatment programs for Indigenous people (Clark et al., 2013; First Nations Health Authority, 2013; Goldenberg et al., 2008; Rusch et al., 2008b; Tang & Brown, 2008). Culturally-safe and gender-specific harm reduction and recovery programs should  123 therefore collaborate with sexual health providers in order to deliver relevant information, testing, treatment, and preventative options.  The need for accessible and effective sexual health resources  In this study, only 9 of the 20 women who tested positive for syphilis had self-reported ever having syphilis. This may have been due to recall bias. In studies among people who use drugs in the United States and who have tested positive for syphilis, low rates of self-reported positivity have also been found. Researchers attribute such findings to low healthcare utilization among people who use drugs, especially in cases of asymptomatic infections (Plitt et al., 2005). However, as 19 of the 20 women with a history of syphilis had received treatment, their hesitation to disclose may have been due to the stigma that often accompanies STIs. In a study among women living in Vancouver’s Downtown Eastside (DTES), Rusch et al. (2008a) demonstrated that women of Indigenous ethnicity had higher scores for both social STI stigma (views about women who have STIs) and internal STI stigma (shame, embarrassment, etc. around having an STI). The authors attributed their findings to the conflicting ideals of female sexuality between traditional Indigenous and western cultures. In their study, Indigenous women who had ever received STI testing or treatment had significantly lower social and internal stigma scores. The authors suggest that having received STI care and treatment may have mitigated some previously-held stigma.  Upon consultations with Cedar staff who verified syphilis treatment, it was discovered that not all women who tested positive had received treatment in the DTES. As described in chapter 6, negative experiences with sexual healthcare providers was described in detail by participants who had utilized sexual health resources outside of the  124 DTES. Discrimination and a lack of culturally-safe, trauma-informed, and gender-specific approaches to care were found to intensify feelings of self-blame and shame around STIs. As such, the hesitation to self-report syphilis positivity in this cohort may be due to having experienced ineffective and discriminatory STI counseling that attached stigma to syphilis diagnoses.  While it is promising that all participants who tested positive had received treatment, inadequacies in care provision highlighted above can greatly jeopardize Indigenous people who do not have access to culturally-safe sexual health resources. Even if testing and treatment are sought, measures that focus on long-term prevention and continuity of care are needed. We were pleased to observe that no participants in Chase or Prince George had ever contracted syphilis. In BC, the majority of syphilis cases occur among Caucasian men in urban areas (BCCDC, 2013). We assume that Indigenous women living in Vancouver are more likely to be exposed to sexual partners who have infectious syphilis. It is important to evaluate how differences in sexual networks between Vancouver, Prince George, and Chase are impacting STI risks.  The potential for an epidemic in other parts of the province must still be considered. The surge of syphilis infections in Canada’s western provinces have occurred in regions where many Indigenous communities are located. Indigenous people are disproportionately bearing the burden of these outbreaks, and sexual health resources that mitigate the ramifications of syphilis infection are greatly lacking in such areas (CBC, 2010; CBC, 2015a; Government of Alberta, 2010; Ogilvie et al., 2009). A longitudinal examination of condom use among Cedar Project participants has demonstrated that both young men and women in Prince George were significantly less likely to use condoms  125 consistently when compared to participants living in Vancouver (Chavoshi et al., 2013). As has been mentioned, tightly knit sexual networks and frequent migrations between Indigenous communities can allow STIs to spread rapidly (Devries et al., 2011; Wylie & Jolly, 2001), particularly for a highly infectious STI such as syphilis (Center for Disease Control, 2014). If syphilis is not recognized or treated, it continues to persist in the body even after symptoms have disappeared. It is readily transmitted through vaginal, anal, and oral sex. While most people do not develop late stage syphilis, those who do will be at risk of paralysis, blindness, dementia, internal organ damage, and even death (Center for Disease Control, 2014). Vertical transmission can greatly endanger neonates, as almost 40% of infants who are infected will die. For infants that survive, congenital syphilis can cause extensive damage to bones, vision, and hearing, and severely delay mental and physical development (Government of Alberta, 2010).  The increased vulnerability of Indigenous women who use drugs to syphilis is particularly concerning, as international research demonstrates that among all STIs, syphilis has the highest probability of facilitating HIV seroconversion and transmission (Chesson & Pinkerton, 2000). The presence of syphilis can increase the odds of seroconverting to HIV during sex by almost 4-fold (Taha et al., 1998).  HIV prevention through STI treatment relies heavily on symptomatic episodes that are identified during an active infection (Korenromp et al., 2000). Mass screening and treatment are only effective in a population with high-risk partnerships who have curable and easily detectable STIs. In any other population, preventative efforts are needed to keep at-risk individuals negative (Korenromp et al., 2002), as researchers have demonstrated that  126 more than 1,000 new HIV cases in the USA were attributed to syphilis alone (Chesson, 1999).   It is critical that sexual health programs offer preventative and treatment options through culturally-safe measures that incorporate the needs and values of the communities they serve. Partnerships between provincial governments and Indigenous health organizations can improve outreach. Indigenous women’s health clinics in particular can act as appropriate liaisons for STI screening, pre- and ante-natal care, and treatment measures for syphilis. Collaborations between non-Indigenous health organizations and Indigenous Nations can help develop best approaches for testing, partner notification, and treatment on-reserves. In particular, screening should be extended to the most vulnerable members of society, which include people who are homeless, self-medicate, and who engage in survival sex work (Government of Alberta, 2010).  Limitations and conclusions  The limitations of this study must be considered. First, findings cannot be generalized to all Indigenous young people in Canada as the potential risk factors for syphilis was only examined among Indigenous women who use drugs in Vancouver. Due to the non-random outreach methodology of the Cedar Project and the cross-sectional clinical testing that was done, the sample may not have included Indigenous young people who are most vulnerable and isolated. However, the connectedness of the Cedar Project team with the community and its rigourous recruitment methodology and eligibility criteria give us confidence that the sample is representative. Second, the Cedar Project Demographic and Nursing questionnaires predominantly rely on self-reported  127 data. Responses may have been affected by both recall and social desirability bias. Third, multivariable modeling was not appropriate for this sample size. A longitudinal examination of syphilis incidence is required to better understand the independent risk factors for contracting syphilis among Indigenous young people who use drugs over time. This will allow for multivariate modelling to be conducted in order to examine the independent determinants of syphilis infection.  This study is the first known exploration of syphilis positivity among Indigenous young people who use drugs in British Columbia. Its findings demonstrate that the legacies of colonization continue to negatively impact the health of Indigenous women. We are particularly concerned about the surge of syphilis in areas where sexual health resources are most lacking (CBC, 2010; CBC, 2015a; Government of Alberta, 2010). To support the long-term sexual health of Indigenous women who use drugs, harm reduction centres, mental health services, and sexual health programming should incorporate culturally-safe, trauma-informed approaches to care that are built upon Indigenous health frameworks. Enhancing telehealth and online resources tailored to Indigenous communities can serve as timely, safe, and confidential platforms to answers questions and connect individuals with appropriate resources. The development and strengthening of such comprehensive strategies can raise awareness about syphilis infection, help identify the need for testing, advocate for preventative measures, and ultimately support positive sexual health outcomes.      128 Chapter 6: “Sex itself is one thing, but there’s so much more to it”: Indigenous young people’s voices on sexual experiences, education, and safety  6.1 Introduction The cumulative grief and social disparities that Indigenous communities in Canada have been subjected to through colonization situate them at higher risk for negative health outcomes (Farmer et al., 1996; Vernon, 2001; TRC, 2015). For over 150 years, European colonizers systematically attacked the Indigenous identity and self-determination through forced removal from traditional lands, cultural genocide, control of resources, and child apprehension (TRC, 2015). In particular, the legacies of the residential school and child welfare systems severely undermined the sexual wellbeing of Indigenous people. In the residential schools, Indigenous traditions that celebrated sex were replaced with strict doctrines that deemed it impure (Pauktuutit Inuit Women of Canada, 2006). Widespread sexual abuse was inflicted by the very perpetrators who preached chastity, abstinence, heterosexuality, and monogamy (Fournier & Crey, 1997, p.129; Milloy, 1999, p. 296). Victims were utterly traumatized and confused about the dynamics of sexual relationships and the meaning attached to sex. This unchecked abuse of power was coupled with enforced silence. Residential school survivors were left to grapple alone with the long-term consequences of sexual abuse, with little support or resources to restore balance to their mental, emotional, physical, and spiritual wellness. The traditional health belief systems that had long safeguarded sexual wellbeing had eroded, greatly obstructing opportunities for healing (Fournier & Crey, 1997, p.129; Milloy, 1999, p. 296). Survivors returned to society with burdens of unresolved trauma, pain, and broken identities. Deprived of the protective effects of family and traditional wellness  129 frameworks, residential school students had internalized what they had learned about total adult control and abuse as methods of child rearing (Barlow, 2003; Fournier & Crey, 1997; Hylton, 2002; Milloy, 1999; Royal Commission of Aboriginal Peoples (RCAP), 1996). Such stressful living conditions were exacerbated by social marginalization and the use of illicit drugs to numb the pains of self-loss. Consequently, families struggling with poverty, substance dependence, and unresolved trauma found it extremely difficult to create safe homes for their children (Chansonneuve, 2007; LaRocque, 1994; Tousignant & Sioui, 2009). The intergenerational transmission of trauma, which includes anger, emotional detachment, shame, and abuse within Indigenous families is described as lateral violence (Chansonneuve, 2005; Walters & Simoni, 2002). When child welfare transferred from federal to provincial agencies in the 1950’s, a per capita funding model incentivized the long-term removal of Indigenous children from what were deemed “unfit” homes. Thousands of children were subsequently apprehended, giving rise to a new wave of collective pain (Chansonneuve, 2005; LaRocque, 1994; Tousignant & Sioui, 2009). Today, child welfare policies continue to interfere with family dynamics by prioritizing the removal of children from their families over supporting family reunification and healing (Christian & Spittal, 2008; Fournier & Crey, 1997). Consequently, Indigenous children remain vastly overrepresented among all children in foster care (Sinha et al., 2011; Statistics Canada, 2016), a lifetime vulnerability which has been associated with negative sexual health outcomes (Clarkson et al., 2015).  The legacies of the residential schools have embedded the topic of sex in deep silence, pain, and shame, and the underlying conditions that perpetuate child apprehension and intergenerational trauma remain largely unaddressed. Inadequate  130 sexual health resources are denying many Indigenous young people access to the necessary support systems that foster sexual wellbeing (Yee, 2010). Indigenous scholars stress that understanding the sexual health risks of vulnerable Indigenous young people can only be done within a framework that considers both the consequences of colonization and the cultural resilience that is inherent in Indigenous people (Kirmayer et al., 2003; Lavallee & Clearsky, 2006; Walters et al., 2002). “Sexual vulnerability” describes the disproportionate burden of the sexual health risks that Indigenous communities bear. These include high rates of STIs, HIV/AIDS infection, and unplanned/teenage pregnancies (Chen et al., 2007a, Myers et al., 1999; Oliver et al., 2015; Pauktuutit Inuit Women of Canada, 2006; Yee, 2010). The concept of sexual vulnerability locates such disparities within the context of ongoing colonization.  To date, no known qualitative study has investigated the pathways to sexual vulnerability or asked Indigenous young people to share their perspectives on the interrelated historical and lifetime factors that have impacted their sexual health, behaviours, and safety. Further, no known study has asked Indigenous young people who face adversity to identify the protective mechanisms that lead to positive sexual outlooks and experiences. This represents a critical gap in research, as investigations of historical and lifetime trauma have empirically been shown to intensify negative sexual health outcomes among young Indigenous people who use drugs to cope with adversity (Clarkson et al., 2015; For the Cedar Project Partnership et al., 2008). As such, it is imperative for intervention purposes to identify both the risk and protective factors that shape and influence the sexual realities of Indigenous young people.  131 6.2 Objectives and rationale  The factors that influence sexual experiences, understanding, and safety for Indigenous young people who use drugs are multifaceted and complex. Qualitative methods “enable health sciences researchers to delve into questions of meaning, examine institutional and social practices and processes, identify barriers and facilitators to change, and discover the reasons for the success or failure of interventions” (Stark & Trinidad, 2007, p. 1). The exploratory and flexible nature of in-depth interviews allows the researcher to not only examine the topic of interest, but to explore and incorporate any new ones that may arise (Schensul et al., 1999). These methodologies have the ability to provide a broader understanding of the interconnected and complex pathways that impact sexual health and can greatly inform quantitative findings. This study used in-depth interviews to centre the voices of the Indigenous men and women who participate in the Cedar Project to understand the historical and lifetime circumstances that impact sexual health. The objective of this study was to grasp a deeper understanding of how intergenerational trauma and other individual, social, cultural, structural, and protective factors influence sexual development, education, behaviours, relationships, and wellbeing for Indigenous people who use drugs. The participants’ narratives helped contextualize the epidemiological investigation of risk factors associated with ulcerative STIs in Chapters 4 and 5. Their accounts unraveled the complex intersections that shape understandings of and experiences with sex from childhood to the present day, which can in turn, inform health programming, policies, and services meant to support the sexual wellbeing of Indigenous young people who use drugs.   132 6.3 Review of study setting, theoretical framework, and participants  This study was informed by theories that recognize the cumulative impacts of forced assimilation on present-day health outcomes among Indigenous families (Chansonneuve, 2005; Fournier & Crey, 1997; Wesley-Esquimaux & Smolewski, 2004). This theoretical approach is also informed by previous Cedar Project studies that demonstrate that Indigenous people who use drugs do so to cope with unresolved lifetime and intergenerational trauma (Craib et al., 2009; For the Cedar Project Partnership et al., 2008). The study’s framework recognizes the strengths and cultural resilience that are inherent in Indigenous people, and are exercised in the face of lifetime adversities (Brown & Strega, 2005; Dion-Stout et al., 2001; Kirmayer et al., 2011). Chapter 1.4 describes the theoretical framework that informed this study’s objectives, methodologies, analysis, interpretations, and recommendations in detail. This qualitative examination of sexual health among Indigenous young people involved conducting in-depth interviews with 28 men and women who participate in The Cedar Project. The Cedar Project is an ongoing prospective cohort study of Indigenous young people aged 14-30 (at baseline) who use drugs and live in BC. The Cedar Project began in 2003 and is governed by a Partnership comprised of Indigenous scholars, leaders, researchers, and service providers. The Partnership provides oversight and guidance to the entire research process. Recruitment is ongoing, with eligibility criteria stipulating that participants be of self-reported Indigenous ancestry and have smoked or injected illicit drugs in the month prior to enrolment. Chapter 3.1 outlines details pertaining to the Cedar Project’s ethical considerations and participant care. Chapters 3.2.1 and 3.2.2 outline details pertaining to the Project’s study design, setting, and recruitment methods.   133 During the months of May-November 2013, Cedar Project research staff invited participants to partake in this qualitative study. Staff informed participants that a female doctoral researcher (N.C.) wished to conduct in-depth interviews in order to better understand the multifaceted lifetime factors that have impacted their sexual health, development, and experiences. Participants were informed that a $20 honorarium would be provided for participating in the interviews, even if they chose not to complete all parts of it.  Interviews with 15 young women and 13 young men were conducted over the span of 7 months. Seventeen participants were based in Vancouver, and 11 in Prince George. However, the majority had spent at least part of their childhood in other towns and cities across BC and Canada. At the time of the interviews, the average age for women was 27.4 years, and the average age for men was 26.9 years. Sixteen participants had experienced sexual abuse during childhood, 18 had been apprehended from their families as children, and 12 had ever been involved in survival sex work. Fourteen participants had received some form of sexual education in school. Twelve participants tested positive for HSV-2, 3 were HIV seropositive, and 2 had tested positive for a history of syphilis.  6.4 Data collection and analysis 6.4.1. Data collection  The interviewer utilized a loosely structured topic guide developed in collaboration with Cedar Project interviewers, nurses, mentors, and Partners. The topic guide explored the following areas of interest: a) unraveling the influences of residential school histories and intergenerational trauma on sexual education, experiences, and safety; b) tracing the  134 influence of family, school, peers, sexual partners, culture, and drug use on sexual decision-making, education, and experiences; c) understanding risk taking or risk minimizing behaviours; d) seeking perceptions of personal sexual health risks and experiences with STIs; e) identifying barriers to sexual safety and health, and to accessing preventative and treatment services; and f) identifying key resources that support healthy sexual development for Indigenous young people who face adversity. Categories of exploration were kept broad to allow relational understandings to emerge about both risk and protective factors associated with participants’ experiences. This study presents findings from topics A-D; the results from the final two topics of exploration are presented in Chapter 7.      Prior to conducting the interviews, N.C. memorized the topic guide to permit natural conversations to occur. Loosely structured interviews allowed participants’ narratives to flow inductively, and sensitive probing on difficult topics facilitated an in-depth, detailed discussion. This method is flexible and allows space for the discussion of any new topics that may arise during the course of the interview (Schensul et al., 2009). This approach also accommodates the nature of storytelling, which is frequently used by Indigenous people when they describe their past and present lived experiences (Brant Castellano, 2000; Tousignant & Sioui, 2009). Interviews were digitally recorded, and detailed field notes were taken after each interview to document any observations, insights, thoughts, questions, and comments that arose.   The researcher continually self-reflected to assess her personal biases, reflexivity, and positionality by keeping a diary of all thoughts and reactions during the interviews and how they may have impacted her research methods and analysis. Frequent  135 discussions with Cedar Project mentors allowed the researcher to evaluate herself with integrity to add credibility to her research process (Koch, 2010). Please refer to Chapter 3.3.4 for complete details on the data collection methods undertaken for this study. 6.4.2 Analytic approach  The data was analyzed using an interpretive thematic approach (Starks & Trinidad, 2007). All data was transcribed verbatim and reread carefully to gain familiarity with the body of information, identify patterns, evaluate contradictions, and explore assumptions. To create codes, statements were categorized into meaningful groups by focusing on the what, how and why components of the feelings, actions, and experiences described in the statements when collapsing data (Starks & Trinidad, 2007). The ‘constant comparison method’ was used to reintegrate the data in order to draw central themes and relationships across all the narratives (LeCompte & Schensul, 1999, p. 75). Codes were combined into overarching themes by identifying, organizing, and analyzing data patterns within the theoretical framework informing the study (Braun & Clark, 2006). Quotes that represented the themes were extracted from the transcripts to illustrate concepts, and context was provided for each quote to enable the judgement of transferability for the reader (Koch, 1994).   The researcher regularly presented the analytic approach and coding scheme to committee members and the Cedar Project Partnership. This was done to help to boost credibility and rigour by addressing assumptions, gathering feedback, and receiving recommendations on the researcher’s methods and interpretations (Golafshani, 2003; Stark & Trinidad, 2007). All analytic claims were compared to existing knowledge in order to map out any congruence or contradiction with previously collected/analyzed  136 data. In order for the study to be dependable, all decisions made regarding the identification and categorization of coding and themes were carefully recorded to establish an audit trail (Koch, 2010).   N-Vivo 10, a software package for qualitative research, was used to organize the data and create the codes. For more details on these analytic methods, please refer to Chapter 3.3.5. 6.5 Findings  Participants’ recollections of the factors that had impacted their sexual behaviours, understandings, and health, were both vivid and vague. This may have been an indication of their level of comfort discussing these memories, or how clearly they remembered them. The narratives of participants who were based in Prince George were very similar to those who were based in Vancouver. This was because the majority of all participants had moved across multiple towns and cities during their developmental and adult years. Their sexual health was greatly affected by the level of stability they experienced during childhood. The devastating impacts of both the residential school and child welfare systems manifested throughout their narratives. More than half the interviewed participants had experienced childhood sexual abuse. They indicated that the assaults had taken place under adverse conditions, including poverty and living with caregivers who were grappling with their own mental and emotional distress for which they self-medicated. The offenders were sometimes family members, and at other times, people who participants became exposed to while in foster care, at parties, while living on the street, or during survival sex work. Almost two-thirds of the participants had been taken from their families and many experienced abuse while in foster care. Not one  137 participant shared having a positive experience with foster parents; they depicted their foster years to be a time of being unloved, unsupervised, not in school, and facing constant uprooting. Their childhoods were predominantly characterized by neglect, loneliness, and trying to fill emotional voids often by finding older, usually predatory, partners to take care of them. These distressing experiences were identified as the origin of initiating drug use to cope with the trauma, neglect, and losses they had endured. Collectively, their sexual realities were described to be a product of multiple lifetime adversities that interfered with opportunities to experience safe and meaningful sexual relationships or access the necessary resources that would have supported their ability to make informed decisions during sex.    This qualitative analysis aimed to unravel these multifaceted factors throughout the course of participants’ lifetimes. Excerpts from the interviews are presented to illustrate the five broad themes (and subthemes) that emerged from the narratives. They include: 1) the role of intergenerational trauma through the residential school and child welfare systems; 2) the impact of sexual abuse during childhood and as an adult; 3) sexual education at school, at home, through culture/traditions/spirituality, prison, and through peers, media, and self-learning; 4) the “intangible” components of sex, which included attitudes around condoms, pregnancy, trust/fidelity, and experiences with STIs; and 5) the role of substance use on sexual health, such as the impact of using drugs and alcohol during sex, the experience of violence in relationships among people who use drugs, and methods to self-protect when using drugs during sex.    138 6.5.1 Intergenerational trauma  Sexual abuse in the residential schools  Throughout the interviews, participants’ narratives highlighted how intergenerational trauma continues to impact Indigenous communities who are grappling with collective distress. Their understanding of the historical pathways that affect sexual health outcomes were largely influenced by their connectivity with Indigenous people and communities. Young men and women who had spent part or most of their life among Indigenous communities discussed the link between cycles of historical trauma and present day sexual health disparities. Many had witnessed the pain that was endured by survivors of the residential schools, and knew of friends, family members, and loved ones who had withstood its horrors. Through their narratives, the transmission of lateral violence was believed to occur because “people did what was done to them”. Participants explained that in the residential schools, traditional spirituality was shunned and Christianity was forced upon students by the same individuals who abused them. They believed that for residential school survivors, faith was lost and replaced with trauma. Such experiences were explained to attach confusion, shame, and guilt to sex, and impede survivors’ abilities to even think about sex:   “They (residential school survivors) lost their faith in priests and nuns, they were the ones doing all that (sexual abuse). So no faith. After the res(idential) schools, Christianity still tries to get forced on them, sometimes it confuses people. Is sex good? Is sex bad? Do we use sex to hurt people, or do we use it to pleasure?” – Flynn, 33   “When it comes to the residential schools, and the abuse, and the many many many other abuses that were experienced there…I’m sure there are people out there that just don’t have sex, and they definitely don’t wanna think or talk about it. It’s traumatizing.” – Miriam, 24    139 Participants reiterated that for residential school survivors, the topic of sex is associated with immense suffering, resulting in an inability to discuss sex in general, which is transferred through generations. This was the case for Isabelle, whose mother was sexually abused as a young girl in residential school. When Isabelle got her period, her mother was unable to talk to her about puberty. For Isabelle’s mother, any conversation pertaining to the human body and/or sexuality triggered her immeasurable trauma, which would cause her to dissociate to cope with the pain:  “My mom was abused (in residential school) when she was little. She wouldn’t talk to us about sex stuff at all. I wanted to ask her about my period even, and she just wouldn’t go there and go all quiet. I guess she just got, uncomfie, like, anything that talked about down there was a no-go for her cause it reminded her (of the abuse).” – Isabelle, 24   Participants conveyed their disapproval of how historical trauma has been and is being addressed. Carinna was raised off-reserve, but lived on-reserve for a few years after she got married. During that time, she met many residential school survivors and was taken aback by the profound trauma that they were living with. Her ex-husband’s Nation had successfully sued the federal government, but Canada’s accountability to the survivors was only in the form of a bank check. Carinna stressed that financial compensation must be supplemented with mental health services to support large-scale healing. In the absence of true accountability in the form of care provision, she believed that ongoing pain would persistently diminish both general and sexual wellbeing: “It’s gut wrenching to hear the stories. To hear. It’s amazing what they did (in the residential schools). To know that, today, the people down here, that are getting these payouts. You’ve already taken everything from them. Can you return somebody’s soul? Can you get a refund for that? Their (government’s) idea is give them money; they’re giving them ropes to hang themselves with. Here I bought you off, I stole your innocence, I messed you up. Sorry I screwed your life. For years and years to come, this is still going to affect Native people.” – Carinna, 28  140 The participants’ narratives demonstrated that intergenerational trauma impacted their sexual wellbeing through lateral violence, not receiving any sexual education at home, and by living with caregivers who self-medicated to cope with unresolved trauma. Parents who used drugs were often unable to adequately care for their children. Being unsupervised increased the chances that children would find themselves in unsafe spaces (e.g. attending parties where drugs and alcohol were used or falling prey to sexual predators). This was true for Emerson, who described that his parents’ drinking interfered with their ability to supervise his whereabouts. Emerson would frequently attend parties as a teenager. On one occasion, he found himself far from home with few options to find his way back. He accepted a ride from a stranger, and was unfortunately molested during the drive back home:  “You would go out till the middle of the night, ending up god knows where, not even knowing how to get back home. It’s not like you could afford a cab, and there are no buses running. So you have to chat someone up to maybe give you a ride.” – Emerson, 27 Many similar accounts were described by participants whose parents struggled to keep them safe and supervised. Such troubled living conditions were identified as the reason for being apprehended and placed into foster care. Foster care  The impacts of unresolved trauma, self-medication, and social marginalization rooted in the legacies of the residential school and child welfare systems, had disrupted the family dynamics of many participants during their childhood. The adversities they had experienced in their own adult lives helped them understand those of their caregivers’. They explained that in the face of ongoing psychological and emotional pain, their caregivers’ capacity to offer safe environments for their children, to transmit love,  141 and to provide lessons about self-care, was severely challenged. Such stories were shared by 18 participants who had been apprehended from their families and placed in the child welfare system. However, for all 18 young men and women, being placed in foster care failed to offer safer living conditions. Foster parents were described as strangers who “did not care”. This resulted in inadequate supervision, missing school, running away, self-medicating, and having difficulty finding stability, all of which directly impacted sexual health. This was the case for Maisie, a 28-year-old young woman, who lived with her grandparents on-reserve as a child. Her grandparents were residential school survivors and drank heavily to cope with their trauma. They struggled to keep Maisie and her siblings safe. Maisie was eventually apprehended and placed into multiple foster and group homes. She felt her fragmented childhood impacted her sexual health as she was often left unsupervised. Maisie shared that she still struggles with stability to this day. She believed that a “better home” would have circumvented some of her negative sexual experiences:   Maisie: “The one thing that I needed was a better home. Put me in a better home. But they just take you from one foster to another, one group home to another. So that stays with you, now I can’t live in one place ‘cause I don’t know what that means. I was always on my own. Up to no good, no one watching over.”  N.C.: “What do you mean when you ‘say up to no good’?” Maisie: “You know, hooking up with randoms, drinking, that kinda stuff.” Most disturbingly, many participants described experiencing maltreatment, including sexual abuse, while in foster care. Jonas, 29, shared that his parents self-medicated to cope with unresolved trauma. He was particularly close to his younger brother, and recalled the devastation of being separated from him. Jonas suffered sexual abuse while in foster care, for which he is still receiving counseling. He believed that instead of being  142 placed with abusive strangers, his care should have been transferred to his extended family: Jonas: “I lived on-reserve till I was 7. My parents had problems, so they took us away. That didn’t help. Foster home to foster home, group home to group home. No one to care for us. My one brother I never saw till we were adults, he was my little brother and I loved him. I got really badly (sexually) abused in foster (care). They should have let us stay together with other family.” N.C.: “Who is they?” Jonas: “The people who took us.”   The legacies of colonization were thus found to impede sexual wellbeing by interfering in the transmission of valuable self-care lessons from parent to child, and through the impacts of familial fragmentation. The pain of being torn from one’s family was severely intensified for 9 participants who experienced sexual abuse while they were in foster care. Their stories described how the culmination of such losses deeply impacted their sexual wellbeing.  6.5.2 Sexual abuse   Childhood sexual abuse  Through the narratives, it was evident that the experience of sexual abuse during childhood critically damaged the sexual wellbeing of survivors. Sixteen of the interviewed participants shared that they had endured sexual abuse as children, with the median age of abuse being 11 years old. They demonstrated immeasurable pain when they spoke of their harrowing experiences, but also portrayed strength and a deep perceptiveness of how the abuse had impacted their lives. The devastating effects of childhood sexual abuse manifested in multiple ways. One of its most distressing consequences was the loss of self-worth that subsequently followed survivors into puberty, teenage years, and adulthood. Every survivor shared how the abuse injured their  143 self-esteem, self-confidence, and self-image. Such negative self-perceptions resulted in an inability to trust others, and interfered with survivors’ ability to connect with intimate partners later in life. This was the case for Effie, who explained how being sexualized and objectified as a child shattered her self-esteem to the point that she would try and hide the womanly aspects of her body when she was around men. She shared how she lost all desire to become close to or connect with another person: “It made me not feel good about myself and others. It made me distant. I try to get close to nobody. Still am like that. I don’t ever like, see me like, outside, wearing revealing clothes. Going through puberty was the worst for me, I always tried to cover my chest. I was uncomfortable around most guys. Still am.” – Effie, 27   In situations where sexual abuse preceded any consensual sexual activity, it created immense confusion about a survivors’ virginity status. This led some to have consensual sex shortly after being abused to settle the confusion. Often, survivors would have sex with multiple partners as a coping mechanism. Carinna had such an experience after she was sexually abused as a child. She shared how the abuse robbed her of her sexual wellbeing. By engaging in multiple consensual encounters, Carinna hoped to replace past experiences with new ones in which she controlled the dynamics. However, she was never able to place enough distance between her consensual encounters and her non-consensual one to ease some of her agony:  “You have this part of you that was stolen, and you try to get it back by, just seeing whether it can finally become normal with someone, so you just have sex to replace old memories with new ones, but it never works.” – Carinna, 28  Survivors explained how childhood sexual abuse caused them to relive pain even during consensual sex. Childhood sexual abuse left survivors to believe that they had a duty to provide pleasure during sex. This perception had carried forward into later relationships, in which they continued to expect minimal personal satisfaction, only pain. Often,  144 resurfacing trauma would cause them to avoid sex completely or dissociate during sex to cope. This was true for Tate, 38, who explained how her body continues to freeze during consensual encounters to this day, mimicking the body language she assumed when she was sexually abused as a child: “I would just lay there while he would finish. I thought that’s what I had to do. I still do that sometimes. Like just get it over with.” – Tate, 38  It was apparent that sexual abuse devastated the psychological wellbeing of children, and inculcated deep feelings of shame, stigma, and fear of judgement. This prevented many children from stepping forward to disclose the violence they were being subjected to. It was particularly troubling to find that some survivors kept silent out of fear of being taken away from home, and be placed in the hands of potentially abusive foster parents. This was true for Mason, a 19-year-old young man, who was repeatedly molested by a male relative who lived in his home. He shared how frequently he considered asking for help. However, he knew of friends who had disclosed and were taken away, only to become re-victimized in foster care. Fear of being separated from his siblings only to endure more abuse by strangers, secured his silence:  “If you would go tellin someone they’d say ‘yea what makes you so special’? Or they’d just take you away and put you in another place where you’d be abused. That happened to my friends.” – Mason, 19  For others, disclosure not only carried the threat of being torn away from home, but rather, intensified the threats that already existed at home. Often, participants were reluctant to come forward in an attempt to protect their younger siblings, or other family members whom the abuser threatened to target. Iris remembered how her sexually abusive foster parent warned that the same would be done to her sister if she ever  145 revealed his actions. Consequently, Iris internalized her confusion, shame, and guilt to safeguard her family in the most adverse of circumstances:  “It was about being ashamed and not knowing. Like, ‘why me’? I was told that if I said anything, they would do it to my younger sister, we shared a room. I felt like it was my fault and I had to protect her, right?” – Iris, 32  Iris shared that sex has always been “taboo” for her as a result of sexual abuse. One of Iris’ younger sisters lived with their aunt, and was raised traditionally in a safe home and never endured sexual abuse as a child. Iris described her sister as sexually “healthy” - in that she did not face the same challenges as Iris (self-medicating, becoming involved in survival sex work, and contracting multiple STIs). She believed that their different upbringing equipped one sister with the power to self-care, and deprived the other of developing such an ability:   “It’s (sex) taboo because of what happened to me as a kid. But for my younger sister, she may have a different story. When my mom got sick, she went to live with my aunt, they were able to be brought up in potlatches, in the culture, and language. And it has a lot to do your early childhood, what happens when you grow up. We all came from the same household, the ones who got abused just don’t care (about self-care during sex). So abuse impacts people’s attitudes towards sex.” – Iris, 32  Through participants’ stories, the feelings of guilt, shame, and resurfacing trauma that accompanied sex and made survivors averse to discussing sex, often resulted in their isolation. This was true for Irma, whose distressing childhood experiences infused into various aspects of her life, such as her ability to remain connected to a strong peer circle. Irma recognized that young people frequently discuss sex, and recalled how she would shy away from her friends during such discussions. She was afraid that if she engaged in the topic, she would make the fact that she had been abused apparent. Irma shared that  146 she eventually withdrew from her peer network in order to avoid having to think or talk about sex:  “Because I was abused, I never talked about sex with my friends. They would talk about it all the time but I just listened. I was always afraid that I would somehow give myself away. They thought I was a virgin and would tease me about it, but I wasn’t. At least, in my body. Maybe in my head I was still a virgin. I don’t know. So I just avoided them whenever those talks came up.” – Irma, 30  Participants’ narratives made it clear that childhood sexual abuse severely damaged sexual wellbeing by isolating victims, instilling misconceptions about their role during sex, reducing their self-esteem, and shutting them down towards the topic of sex. Ultimately, these effects interfered with their sexual outlooks and capacity to discuss sex openly, safely, and without fear. As a result, their ability to access counseling, sexual education, and sexual health services was challenged. Ultimately, the cumulative impacts of sexual abuse made it very difficult for them to heal or find safety, comfort, and meaning in relationships. Experiencing sexual abuse as an adult    Experiencing sexual abuse during adulthood did not present with the same magnitude of confusion or shame, but continued to profoundly impact relationships, the ability to trust others, reduced self-image, and attached pain to the topic of sex. It was troubling that the concept of “adulthood” was described by participants as the years following the mid-teens (14+), when they were still very young. Participants who experienced sexual violence as teenagers found it difficult to establish safety or intimacy in later relationships. They explained how sexual assault diminished the value and significance of sex for them. The majority of discussions around sexual abuse during adulthood pertained to survival sex work. Young women described extremely violent  147 encounters with clients who preyed on their vulnerability. Pilar was repeatedly raped when she was engaged in survival sex work. This led her to remain on guard at all times, even in her non-client relationships, impacting her ability to trust her partners: “It (sexual abuse during survival sex work) made me feel very uncomfortable about sex. And nobody did anything to make me comfortable. Now, I’m very careful. I’m always alert, like I know there are bad people out there who may want to hurt you. So I’m always careful. Of everyone.” – Pilar, 23  At the time of the interview, Iris was actively involved in survival sex work in the Vancouver’s Downtown Eastside (DTES). She believed that many of the men who seek sex in the DTES are predators. On occasion, the pain of drug withdrawal would force Iris to exchange rough sexual acts that she would have otherwise not consented to. These experiences made her fearful of both men and sex, and she perceived sex to be a tool that men used to inflict pain upon vulnerable women:  “People come down here because they know they can prey on people that they see as weaker. Sometimes women are addicted and the promise of good dope takes them places they don’t necessarily want to go. That makes you scared. Scared of men. Scared of sex.” – Iris, 32    Participants who had endured sexual abuse as young adults shared how they developed an erroneous understanding of what consensual sex entailed. When Arya was 16, she lived with an older man who drank heavily, was violent, and eventually forced her into survival sex work. At the time, she was unable to refuse his sexual demands, and felt she had a duty to provide pleasure to him and the clients he brought home for her. This belief persisted until she met a partner who helped her discover that she, too, can derive pleasure from sex. After years of maltreatment and exploitation, she was on her path to healing through a partnership that made her feel safe, cared about, and listened to. For  148 Arya, the experience of a healthy relationship allowed her to differentiate it from an unhealthy one:    “I was 16 when I was with this guy. First he was nice, but after, he started making me have sex with his friends, and other guys for drugs (and) money. I wasn’t getting any pleasure, just pain, I felt like it was my duty to please the person. And now, to know the difference between making love and sex. Making love is when you have feelings for the person, and you can talk about what you like. I was confused for the longest time. I didn’t know the difference.” – Arya, 28  Importantly, even when sexual abuse was not personally experienced, tales from friends and family members who had been assaulted impacted attitudes towards sex. Miriam’s mother was involved in survival sex work when she was young, and had been raped countless times. Her traumatic experiences with men led her to believe that she was a lesbian. What her mother endured served as a cautionary tale for Miriam, who shared that she had the same difficulty establishing trust with men:   “My mom was a sex trade worker before, she had issues with men, to the extent that she thought she was a lesbian for years, but through counseling she discovered she wasn’t a lesbian, but that she had issues with men because she had been raped so many times. That becomes even worse when it happens to them young. I always remember what happened to her and know to be careful.” – Miriam, 24   Participants’ narratives on sexual abuse during adulthood spoke to its destructive impacts on sexual health. The lost intrinsic value of sex, and the inability to trust others or be able to differentiate between healthy and unhealthy relationships greatly distorted sexual outlooks. As bonds of love are crucial for emotional wellbeing, sexual abuse was found to not only threaten the sexual health and safety of victims, but denied them their rightful opportunity to form meaningful relationships with intimate partners.   149 6.5.3 Sexual education Throughout the interviews, participants were asked to describe any lessons on sexual health, safety, relationships, and/or puberty they may have received during their developmental years. The majority never had an opportunity to learn about sexual wellness from a trusted, reliable, and informed source in a safe environment. Participants overwhelmingly spoke to the lack of adequate sexual health resources for Indigenous young people. However, in the face of such obstacles, they demonstrated resourcefulness. Roman, 29, and his friends lived in a small community with limited resources. He shared how they would reach out to telephone operators to ask their questions: Roman: “I know that a whole bunch of us if we had questions around drugs, alcohol and the odd sex question, we would go to the payphone and telephone the operator and that worked.” N.C.: “Like what kind of questions?” Roman: “We once called to ask where to get condoms and how to put one on. Or one time, it was about oral sex.” N.C.: “What did the operator say?” Roman: “They told us about this health clinic we could go to but it was too far. They tried to answer questions best they could.”  While participants highlighted the shortage of sexual health resources, they did recall obtaining both informal and formal modes of sexual education (sex-ed) throughout their life. The home environment, school, and culture/religion/spirituality were understood to be formal sources of education, as lessons were transmitted by someone older. Other important, but informal, sources of sexual education included peers, the media, self-learning, and prisons. Sexual education in the home environment   When recollecting past lessons on sexual health, participants identified the home as their earliest source of sexual education. This included their own homes as well as those of family members or friends whom they would visit or stay with. Experiences of  150 sexual health education in this environment ranged from positive to strained. Very few participants reported having sexual health discussions with trustworthy adults whom they felt comfortable with. Most attributed this to their caregivers’ struggles with substance dependence and unresolved trauma. As such, the sexual education participants received in the home environment was described to occur mainly through observation. Ten participants described learning about sex at home by witnessing it between people who were drinking alcohol or using illicit drugs. Such scenes elicited immense confusion and fear in their young minds. Emerson, 27, remembers how this impacted his perception of gender roles during sex, and his belief that alcohol was a necessary component of having sex: “I figured it (sex) out seeing my uncles doing it to women that were passed out at parties. I would question it: why they were doing that, why they drank, and why they would do that to different women? Is this how it’s supposed to be done? – Emerson, 27  As the home environment was identified as a primary source of sexual education, participants were asked if they felt comfortable teaching their own children about sex. The ability to do so was largely influenced by participants’ relationships with their own guardians. Those who described positive relationships with their parents articulated healthy understandings of sex, relationships, and safety. They demonstrated tremendous communication skills when discussing ownership of their bodies, had a late sexual debut, and were knowledgeable about sex, STIs, and self-protection. All had been raised at home and/or in their communities by their parents or extended kin, and none had experienced childhood sexual abuse. Each spoke of their parent figures highly and as of someone who had nurtured their sense of self-worth. This was the case for Zane, whose  151 uncles and cousins taught him about sexual safety, values that he was able to pass down to his younger sister (whom he was a guardian of as their parents had passed):   “My uncles and cousins were there to talk to me about sex. Kids need role models. That helped me talk to my sister about it, tell her how to protect herself and how men are evil. I saw the walks of shame of other women and didn’t want her to do that walk.” – Zane, 32  Kane, too, recalled his childhood fondly, he was raised by his father and extended family members in Northern BC. He differentiated between his own healthy sexual experiences as a teenager and the many unhealthy ones he had witnessed among his friends. Kane believed that the reason he was spared such negative outcomes was because of his father, who Kane described as a strict parent that kept him under close supervision:   “My father, would give me a curfew. If I came home (late), I was in trouble. He wouldn’t hit me, just would say ‘go to your room’. My father knew where I was; no one else I knew had that” - Kane, 29  Participants who did not have a strong relationship with a parent figure communicated their desire to transmit lessons about sexual safety to their children, but found it difficult to do so as they lacked an example to draw from. The same historical and lifetime challenges that had prevented many of their parents from teaching them about sex also impacted participants’ ability to guide their own children. The difficulty of breaking the cycles of intergenerational trauma was strikingly evident. This was true for Arya, who had been sexually abused and placed into foster care, where she endured even more maltreatment. Arya turned to drugs to cope with her pain, and as a result, had her daughter taken away from her. She described the crippling fear she felt for her daughter’s safety, but found that her own life circumstances challenged her ability to support her daughter:   152 “I’m scared. My daughter’s going to be 12 this year and I think of all the stuff when I was 12, I was doing all sorts of things, I’m terrified. I don’t know how to be a mother to anybody because I never had one.” – Arya, 28  Still, the resilience of participants to overcome their lifetime adversities was repeatedly demonstrated. Iris had been separated from her children due to her struggles with self-medication. She conveyed frustration and helplessness about having her children taken away, but found motivation to seek recovery in order to secure visitation rights. Her family was her source of strength, and she utilized any available opportunity to guide her children by using her own experiences to inform and caution: “With me and my daughter, I haven’t had her since she was one. I know she’s angry with the situation, but I do talk to her when we do have a good relationship. I tell her to use condoms and what happened to me. I try to keep clean enough so that I can see her.” – Iris, 32 Through these narratives, the role of family connectedness on producing positive sexual outlooks was clear. Once again, historical and structural barriers to sexual health education were demonstrated for participants who had been taken away from home or whose parents were coping with ongoing trauma and marginalization. As such, sexual education was often left to be received through other sources. Sexual education in school   Only fourteen participants had partaken in a sexual health education class during their schooling years. Participants who had not received sex-ed attributed missing the session to irregular schooling due to being in multiple foster homes, or because they were attending Christian schools that did not offer sexual education curricula. Participants who had received some form of sexual education at school described the experience as uncomfortable, ineffective, and lacking in opportunity for safe dialogue or follow-up counseling. Fear of being teased and judged by their peers prevented many from asking  153 questions during the sessions. In addition, the small community setting that some participants had received sex-ed in was identified as a major barrier to open discussion, as many educators were known to students outside of school:  “At school, everyone was Native, and the counselors were there to help and to tell us what to do but kids didn’t wanna go. It was weird, like I know this guy.” – Benson, 25 “I wasn’t able to get information from the counselor because they were a family member, it was my cousin, it was a conflict of interest.” – Roman, 29   Sex-ed at school was criticized for only scratching the surface of the sexual realities participants were living with and for being inadequately designed to meaningfully serve the audience they were delivered to. Participants who were survivors of childhood sexual abuse were most critical of sex-ed. Their narratives recurrently spoke to the deepened sense of shame, discomfort, and confusion that emerged during and after the session. They were mortified by how this sensitive topic was delivered in front of the entire classroom, without any regard for the reactions that it may induce in children who had endured sexual abuse. In particular, the “good touch/bad touch” component of sex-ed was recollected as extremely unsettling. This lesson was described to involve dolls and diagrams, and the educator would point to various body parts to differentiate between appropriate and inappropriate physical contact. These relayed messages stood in stark contrast to the children’s personal experiences. The poor delivery of sexual education triggered the trauma of survivors, some of who had crippling panic attacks during the session. Iris shared how helpless and confused she felt when the sex-ed counselors discussed “bad touch”:  “It was kinda confusing because I got sexually abused at a young age, so when it came to learn about that kinda stuff, I felt that I had already lost that part of my life. This lady is telling me about good touch, bad touch, but I’ve already been bad touched, so what do I do now?” – Iris, 32   154  Ultimately, the messages that were conveyed during sex-ed were done so ineffectively that the information was often left unabsorbed. The triggering of trauma and shame for survivors of childhood sexual abuse turned an experience that was meant to be educational to one that was psychologically, emotionally, and mentally disturbing. Participants provided detailed recommendations on how to address the shortcomings of sex-ed programs in school. Their voices are shared in Chapter 7.4.2.  Traditional teachings, culture, and spirituality   The interviews explored relationships between culture, traditions, spirituality, and sexual outlooks. Participants who had connections to their Indigenous culture during their developmental years spoke of culture and spirituality interchangeably. As a tool of sexual education, culture was recognized as a powerful source of positive sexual outcomes. Kane, a young man who demonstrated healthy understandings and notions around sex, shared how as a boy, he would often accompany his father to traditionally gather food. It was during these traditional activities that his father transferred values on respecting all living things, including his own body:   “My dad took me out in the spring and fall, we collected food the old way. Fishing, hunting, preparing the meat, we did that together. Those were the times he would talk to me about how the ground, the animals, life, are to be respected, and how we should respect them and respect ourselves.” – Kane, 29  Culture emerged as a protective factor for sexual health as it facilitated healing and instilled self-esteem during adulthood, especially for participants who had not been raised in their ancestral ways. As the majority of participants had sought cultural practices to overcome addiction, culture helped mitigate the negative impacts of substance use on sexual health. Further, participating in traditional practices allowed participants to  155 connect with and become knowledgeable of Indigenous wellness frameworks that support both general and sexual health. This was especially true for participants who were two-spirited, who located their identity in the esteem that Indigenous cultures traditionally grant to two-spirited people. This was the case for Jonas. While he had some connection to his culture during childhood, he became immersed in it to overcome trauma and addiction. Through these experiences, he learned about the reverence of two-spirited people in Indigenous culture and drew great strength from it, which motivated him to protect himself both spiritually and physically:  “I got clean for two years, and part of my healing process was being part of traditional stuff, dancing, and sweatlodges, and being in the fire. It helped. It got my mind off of everything. There was a spiritual connection. I was balanced emotionally, mentally, physically. I felt like I belonged. That’s where I learned about the two spirited roles. I seeked it (cultural lessons) out myself. That helped me feel good about myself. To respect my body.” - Jonas, 29 Jaxton had been raised in a Christian household. As a two-spirited man, Christian teachings never offered him any spiritual comfort. After becoming involved in traditional culture, he found an important source of strength and hope. He located his spirituality in the power of traditional teachings, and advocated for their role in nurturing and restoring sexual health and wellness for Indigenous people:  “From a cultural standpoint, before the residential schools, it (sex) was normal. Those traditions should come back.” – Jaxton, 28  Participants who had been disconnected from their culture demonstrated the desire to access traditional ceremonies, practices, and spirituality. Lack of cultural connectivity was attributed to being in foster care, leaving their communities, or the perceived inability to engage in spiritual practices due to drug use. Miriam was raised by her mother, but grew up in Vancouver, far from her Indigenous community. Miriam shared  156 how she wished to be more connected to her culture, especially to overcome substance dependence, but believed that she was unable to do so because of drug use: “I’ve sought a lot of support. I’ve always been self-aware of what I’ve needed and where to find it. I don’t know. Culture is what I need. I wish I had more access to my history. I really wish I could know more about my tribe and my history on my Native side. I gotta overcome my addiction first though. But I need culture to help me with that. It’s a chicken or egg thing.” – Miriam, 24  Participants were asked to discuss puberty and whether they were prepared for the physical and emotional changes that accompanied it. Only two had their coming-of-age honoured with traditional puberty rites. The continued impacts of colonization and the losses of such valuable rites of passage were, regrettably, obvious. This was particularly the case for young men. Emerson spoke of puberty as a time of heightened sexual desires and predictable physical changes. He placed little emphasis on the spiritual, emotional, or mental supports he may have required at that sensitive juncture:   “Puberty wasn’t a big deal. I’m a boy. You get some armpit hair; your voices go funny and you get horny! Haha! Not much to worry about.” – Emerson, 27  Young women’s recollections of coming-of-age also highlighted the losses of traditional resources that support transition to womanhood. Women recalled their first menstruation as “shocking” and “disgusting”. Discussions about menstruation and the changing female body occurred largely after the fact, if at all. Some young women addressed their questions to their mothers, sisters, and aunties after their first period. However, many had to rely on media, friends, and themselves to learn about their bodies. When participants were asked whether they would have benefitted from a coming-of-age ceremony, many thought deeply about the question, and all answered in the affirmative. Helena was one of the young women who remembered her first period as shocking. She shared that she menstruated at age 9, before she received sex-ed in school. Helena had lived with her  157 grandmother, who never discussed matters of sexuality or puberty with her. As the only girl in the family, she had little sexual health knowledge or sources of support. Helena shared that a coming-of-age ceremony would have circumvented the shock she felt when she had her first period, as she would have anticipated its arrival positively:  “I didn’t know about periods. If someone had told me about it and if it was done like a whole thing (ceremony) like I’ve seen them do on this other reserve when I was living there, it wouldn’t have been so shocking or gross and just normal, even good.” – Helena, 25  Participants went on to attribute the loss of cultural traditions and ceremonies to the Christianization of Indigenous people. Those who had been reared in Christian households recalled discussing sex with their caregivers to be difficult, even impossible. For many, sexual education was unavailable at school. Strict Christian teachings inculcated a great sense of fear and guilt with respect to sex. Tate’s mother had been sexually abused in residential school, where religious doctrine taught her that sex was impure - a lesson she passed to her own daughter. Tate believed she used this lesson to make sense of her own experiences as a child: “My mom tried to raise me Christian. She’d tell me and tell me ‘it’s (sex) a sin. It’s dirty. It’s a sin.’ I didn’t really talk to my mom about these things because she wasn’t comfortable talking to me about it. I think maybe because she was abused (in residential school) and she didn’t like talking about sex. Church also said it was a sin, so I didn’t know who to ask.” – Tate, 38  Austin, a 26-year-old man, ran away from home when he was no longer able to live under the stringent religious rule of his adoptive parents. He was frequently propositioned for sex in exchange for money and housing when he was surviving on the streets, and eventually contracted HIV through sex. He displayed great shame and self-blame about his illness. The reluctance of Austin’s adoptive parents and educators to provide him with any sexual knowledge left him to learn about it on his own, with dire consequences:   158 “Never had sex-ed in Christian high school. They don’t do it there. It was frowned up. Couldn’t talk about it. I learned on the streets and paid the price.”  – Austin, 26  Zane discussed how the transference of traditional practices pertaining to sex and healthy relationships had been disrupted in Indigenous communities due to the legacies of colonization, and stressed that its rekindling was fundamental to sexual wellbeing. Zane was one of the young people who articulated healthy understandings of sexuality, and attributed his awareness to his grandmother, who passed down invaluable traditional teachings about sex to him and his sister:  “Listen, our teachings tell us how to be good, and just, how to BE. There are rules. Men have roles. Women have roles, and this is how men and women should be together. But kids need to learn these lessons from someone good. Someone who knows the teachings, and isn’t afraid to tell kids how it’s done right, and how it’s done wrong. We don’t have enough of those people. Me and my sis, we were lucky, we had our grandmother, and she knew about the old ways and taught us kids to respect ourselves and each other.” –	  Zane, 32  Peers  When discussing sexual education during youth, peers were frequently cited as a source of information, particularly for young people who had been in foster care or whose guardians had been residential school survivors. This was true for Natalia, who had lived with her mother and grandmother as a child. Her mother had survived residential school, and used drugs to cope with her pain. Natalia’s mother never talked to her about puberty or sex, and their relationship was often strained due to drug-related bursts of violence. When Natalia menstruated, she turned to her female friends for support:  “I didn’t know that I was going to get my period. I was at battles with my mom at that phase in life. It was really hard. My friends from school helped me to understand that part of it, taught me how to use a tampon, everything pretty much.” – Natalia, 29   159 Many young men recounted having difficulty discussing sex with teachers, parents, or counselors, and relied on their peers to learn about women and relationships. This was mainly approached through story sharing. However, such conversations did not provide opportunities for constructive educational discourse, given that their peers were of similar age, backgrounds, and sexual knowledge. Young men shared that they were reluctant to demonstrate a lack of knowledge or experience, as asking too many questions would have subjected them to teasing. Irvin, 22, would use humour to inquire about his friends’ sexual experiences, but found it difficult to engage in “serious” conversations regarding any feelings, questions, and insecurities he had about sex: Irvin: “Being a kid, I was always curious (about sex), so I was always cracking jokes and making fun of people. Like ‘haha you did it! Yea man what did you do last night’? I was kinda scared to come out with that stuff to anyone. I don’t know why, it was just weird, like I would joke about it but I wasn’t comfortable actually asking serious questions.”  N.C: “Do you think you know why you felt too shy to ask?” Irvin: “Cause guys don’t want to admit they don’t know anything. Everyone wants to be a stud. So you just play along.”  N.C: “What kind of questions would you have liked to ask if you were comfortable?” Irvin: “Anything really. I wasn’t a player but they didn’t know that and I wasn’t gonna make them think I was like a loser or nothin’. I didn’t know some stuff. Like ‘hey, how long are you supposed to last?’ Haha!”   Conversely, for young women, the challenge was not asking questions, but rather, receiving truthful answers. Maisie described how stereotypical gendered expectations label young women who are knowledgeable about sex as promiscuous. Such fears led her friends to pretend they knew very little about the topic:  “I could ask my girlfriends for help but lots of them played coy. I knew they were doing it, but they pretended they were all goody two shoes.” – Maisie, 28  Although peers were not the ideal source of sexual education, a strong social network provided support and a sense of belonging. Those who did not have peer circles recalled  160 feeling isolated. This was described by participants who were two-spirited, who had been taken away from their families, and/or had endured childhood sexual abuse. For them, sexual education was often obtained through the media or self-learning.  Self-learning   Through the narratives, participants’ self-learning was found to be essential to sexual education. Even if young people had received sex-ed from parents, schools, or other sources, their personal experiences were described to have made significant contributions to their understandings about sex. Self-learning was described as the main source of sexual education for most women, as very few had received sexual education at home, and were often not comfortable to have candid conversations with their girlfriends. This was the case for Natalia. After discussing puberty, she went on to share that she learned about sex all on her own. She described that she had great difficulty discussing sex with her peers, and attributed this to the silence that surrounded sex in her childhood home: Natalia: “I learned all by myself. I couldn’t talk to anyone…so who would I ask? I was too shy to ask my dad when I went to him.”  N.C.: “What about your friends? The ones that helped you when you got your period?” Natalia: “I could have asked them, I guess…but. I don’t know. I just didn’t. I don’t know I think all the hush hush about sex that was in our house just made me not talk about it with anyone else. I lost those friends when I moved to my dad anyway, so...”  Self-learning was occasionally the only mode of learning for participants who were taken away (or ran away) from home and who had survived living on the street. Unfortunately, this mode of “learning” often occurred through the devastation of contracting STIs. The detrimental consequences of intergenerational trauma emerged once again. Theon had been sexually abused and ran away from his foster home when he was a teenager. He  161 shared that while he had learned about sex in school and through media, the majority of his learning came directly off the streets. Theon’s fragmented and painful childhood left him homeless and dependent on drugs to cope with trauma. He eventually contracted HIV by having unprotected sex while he was high: “I learned in school and TV and stuff. The other half was me figuring it out on my own. But growing up on the street, you learn faster, it’s more direct. I got HIV from a girlfriend cause I wasn’t wearing a condom. I was too high and didn’t care.” – Theon, 33  Participants explained that self-learning was inevitable when communities remain silent about sex. In their narratives, they expressed incredible frustration about the consequences of having been uninformed as adolescents. This was the case for Isabelle, who grew up in a small community and had never received any sexual education. She had an unplanned pregnancy at the age of 13 that she had to terminate. She demonstrated immense pain when she spoke about the abortion and later described how she fell into depression over the guilt. The distress of withstanding this loss at such a young age was still very apparent more than one decade later: “I didn’t learn the role of any of it (condoms). I had no idea how a guy put one on. Nobody there to tell me. It’s really sad, I was making choices I had no idea I was making. I had an abortion at 13. I didn’t know about the pill; I didn’t know anything.” – Isabelle, 24  Self-learning was highly evident among two-spirited participants, who claimed they knew they were “different” during their developmental years, but did not know how or why. As young people, they described feeling very isolated, fearful, and confused about their feelings, and experienced difficulty approaching a trusted person to confide in and ask questions of. Jaxton shared that as a teen, he lived in a strict Christian household and attended Christian schools where there was very little discussion about non-heterosexual  162 identities. Jaxton knew he was different and shared how he isolated himself as a teenager. He was only able to make sense of his feelings when he moved to the city and met other gay men: “I kinda found out on my own. In high-school, I didn’t know anything about gay people. I kinda like hid all through my adolescence. When I was 22, I found out there was other people like me. I started going out and discovered that lifestyle.” – Jaxton, 28  The lack of sexual discourse and stigma attached to sexual activity was found to devastate sexual wellbeing by preventing young people form learning valuable lessons about their sexual identities, and how to protect themselves from STIs and unwanted pregnancies. As such, self-learning was identified as the primary source of knowledge for participants who continued to be impacted by intergenerational trauma as children and young adults, often with destructive consequences. Media  The role of media as a tool of sexual education spoke to the immense dearth of appropriate, safe, and realistic sexual education resources that help young people make informed decisions. Movies, television, and pornography were identified as sexual education tools, but were perceived negatively. Participants explained that misconstrued portrayals of sexual dynamics were felt to create misconceptions about sex. Arya shared that romantic depictions of relationships in films create unrealistic expectations that lead young girls to seek out love and comfort from older men. She noted this to be especially true for young women who have been abused or not loved, as it was for her when she was younger:   163 “People (men courting younger girls) talk about stuff like it’s a movie, where the fuck did you get that from? Did that really happen? When I was just a kid, I found a guy who was older than me, and he said ‘I will take care of you’, little did I know he was just a pedophile.” – Arya, 28  Participants shared that many young people watch pornography to learn about conventional and non-conventional sexual practices. Zane believed that pornography gives young men unrealistic expectations about their own performance and is disrespectful towards women. He connected the use of media as a tool of sexual education to the absence of appropriate sexual education sources for young people: “It’s the media. It destroys people’s respect for sex. These flicks make the guy look like he can go on forever, and if the woman is moaning and screaming. That’s not real life, so you got guys thinking they’re inadequate and that women all have to do acrobats, it just messes you up till you finally grow up and realize oh shit this ain’t how it works! People are raised by T.V. You need to be raised right.” – Zane, 32  The Internet was cited as a frequent go-to source for sexual information, particularly for individuals who were reluctant to speak directly to others about sex, or felt that their questions would render judgment. This was true for Pilar, who described that she had questions about pregnancy for which she turned to Google. In other parts of her interview, she explained that she has a regular doctor in the DTES whom she trusts, but requires appointments to be made months in advance. Pilar explained that she avoided walk-in clinics, due to the high turnover and random assignment of physicians in these clinics. As a woman who was involved in survival sex work, her past experiences with unfamiliar doctors had left her to feel discriminated against. As a result of these negative experiences, she turned to online sources rather than healthcare providers to have her questions answered:  164 “I Google it! A couple weeks ago I wanted to know how long sperm lasts inside the vagina, and Google told me 3-4 days. I don’t want to ask a doctor a question if Google can give me the answer.” – Pilar, 23   Social institutions such as the healthcare system, prisons, and communities were also discussed as educational platforms that shaped understandings of sexual health. The role of prisons is discussed below. The functions of the healthcare system and community setting as sources of sexual education are discussed in Chapter 7, as participants largely spoke of them within the context of how they can be improved, rather than how they contributed to their sexual development.  Prison   Seven of the thirteen participants who had ever been detained recalled obtaining information on sexual safety, STI testing, and drug counseling while they were serving time. For four participants, this was the first time that any sexual health services had been offered to them, speaking to the gross systemic failure of current sexual health programming. Natalia was offered STI testing in prison. She was raised in a small community and had very little prior information about STIs. She identified prison as her very first source of sexual health education.  “I got them (STI testing) done in jail. That’s the first time I heard about them. It was good, there was a woman (nurse) there who explained a lot of things, I had questions and she answered them.” – Natalia, 29  Participants spoke to the importance of sexual health programs in prison, as they described the prevalence of unsafe and/or forced sex among inmates. They recognized that obtaining sexual education and testing in prison allows people who are serving time to become more informed about sexual health in general. Benson, 25, also received HIV testing and STI information while he was in prison. He felt that the HIV testing was  165 related to both needle sharing and sexual activity among inmates, and stressed that STI testing could mitigate a potential for contracting or transmitting STIs both within and outside of prison: “They do HIV testing and awareness in jail, people can get tested. It’s not like you have anything better to do, might as well…I guess it’s good though, you learn something, but I dunno, is it cause of sex? Or are they worried about the people who are shooting (up)? It’s good they do it, otherwise lot of people can get sick. Then they go back out and make their girlfriends (or) wives sick too.”  – Benson, 25 In summary, the education sources that participants had received sexual health information from collectively spoke to critical shortcomings of the social institutions responsible for dispensing culturally-safe and trauma-informed sexual health education. This forced many young people to learn about sex through other avenues that were often ineffective, and even dangerous. As children and young adults, they were often unknowingly making decisions, and left to deal with the devastations of STIs, unwanted pregnancies, and traumatic relationships.  6.5.3 The “intangible” components of sex Through the narratives, other influential factors that set the precedent for outlooks, beliefs, and behaviours around sex emerged. These included attitudes towards condom use, trust in relationships, self-perceived risks, and experiences with STIs and pregnancy. The term “intangible” was used to describe these elements collectively, and was inspired by Zane, who revealed this philosophical take on sex:  “Sure you got sex itself. Sex itself is one thing, but there’s so much more to it. So many parts. Parts that you can’t even feel, that aren’t part of the sex, but still are. You know? They’re operating and you don’t even realize they’re there! It’s the intangible pieces that really make sex more than just the act.” – Zane, 32       166 Attitudes around condom use   Condom use was found to be largely dependent on the type and length of partnership, and gender and power roles. Generally, condoms were viewed favorably and identified as barriers to pregnancy and/or STIs. Women who were engaged in survival sex work shared that condoms served the additional role of differentiating between client and non-client relationships. Condoms were perceived necessary in new relationships, which were defined vaguely as those in which the partner was not yet “well known” or “trusted”. When asked, the transition to a known partner was described to take between 2 weeks and 6 months. Most women claimed they would refuse sex if a new partner declined to wear a condom, and most men stated that they would use a condom if a woman asked them to. Poppy, 17, would always use condoms with new partners and conveyed that sex without a condom was non-negotiable. Poppy had not endured childhood sexual abuse, had received sexual education in school, and was raised in her community by her family, specifically, her older sister who Poppy spoke fondly of as someone who guided her. It was evident that her stable childhood and presence of role models allowed her to demonstrate strong and assertive communication skills that helped her control her sexual environment: “Oh it’s natural for me. I have no problem (asking to use a condom). They get mad but I say ‘you know what? If that’s all you want then see you later!’”  – Poppy, 17 While the intent to consistently use condoms was communicated by most women, those who had lived in (or still visit) small communities described their reluctance to purchase condoms while in these areas due to confidentiality threats and fear of judgment. When faced with such perceived threats, young women often relied on their male partners to supply and use the condoms. When asked whether pregnancy would invite comparable  167 fears and reputational threats, Carinna responded that pregnancy was socially looked upon as the product of a committed relationship to one man, whereas condoms were seen to suggest promiscuity:  “It’s like if you get pregnant, it’s cause you’ve been with your old man, but if you use condoms, you’re fucking around.” – Carinna, 28 One concerning finding was the discrepancy between whether condoms should be used and whether they were used. This was most evident among young men who communicated that although condom use was important, it did not determine whether the sexual encounter would take place. With respect to condom use, the interviewed young men unanimously appointed women as the ultimate decision-maker. Irvin and Emerson both advocated for condom use, but they shared that they had refrained from doing so when their female partner asked them not to use one. “You should wear a condom every time, depending on…well it’s up to them but I think condom use is the right way to go.” – Irvin, 22   “I told her, ‘I’m not gonna have sex without me using a condom and that’s that’. After a while she had to agree, well she didn’t have to, you know. I’m not gonna say ‘no’ to her.” – Emerson, 27  Men who were the clients of women engaged in survival sex work stated that on occasion, they would be asked not to use a condom. Young men described that women involved in survival sex work use their intuition and people skills to assess regular clients and determine if condoms were necessary. However, women actively involved in survival sex work stated they would invariably use condoms. Iris shared that for her, the extra money was not worth the risks that accompanied unsafe sex:  “If they don’t want to (use a condom), I say ‘see ya!’. What? $50 is gonna cover me having AIDS? To me it isn’t worth the risk.” – Iris, 32   168 Yet, women who were no longer involved in survival sex work shared that on occasion, they had forgone condom use due to offers of increased payment, when they were with a familiar client, or while they were going through withdrawal: “I would always try and use condoms with them (clients). If I didn’t, it was cause I was desperate for drugs.” – Isabelle, 24   Unfortunately, condoms were not perceived as necessary during oral sex, irrespective of partner type or sexual orientation:  “He didn’t want to and I didn’t argue. He just went down on me. In that situation, we didn’t need to use one. I thought about it.” –	  Jaxton, 28  While the majority of participants recognized the importance of condom use in new/client relationships, power dynamics were found to significantly impact that use, as both men and women recounted situations in which their desire to use condoms was not satisfied due to their partner’s reluctance. Women who engaged in survival sex work shared how refusing to have sex without a condom could result in violence. When they were in such situations, they explained that they try and escape or simply succumb in order to minimize physical danger. Occasionally, clients who initially refused to wear condoms would relent, but subsequently remove the condom during sex. Poppy, 17, described that despite refusing to engage in unsafe sex with clients, condom negotiation had the potential to lead to violent encounters:  “It’s very dangerous (condom negotiation), sometimes they will be very forceful and try to take off the condom, or force you to have sex with them without one.”  – Poppy, 17 Trust and fidelity in relationships  Condoms were not viewed as barriers to intimacy, but rather, as barriers to trust. Participants reiterated that using condoms depended on the seriousness of a relationship. Condoms were wholly perceived as unnecessary in long-term relationships. Participants  169 in such relationships reported using other forms of birth control (e.g. the pill or the pull-out method) if they wanted to avoid pregnancy. As previously stated, participants reported they would stop using condoms if their partner was felt to be “known”. This was described vaguely, as someone they felt they could “trust”, an assessment that was informed by their intuition and people skills. The timeline in which this sense of knowing occurred varied from a few weeks to months. For young men, the timeline was generally shorter. Although participants stated that they would ask new partners about STI testing, they did not request and inspect the test results, because they felt it would convey mistrust. Requesting condom use with a regular partner was generally reported to provoke suspicion for both men and women. This was the case for Irma, who questioned her regular partner’s motives when he would consistently ask to use condoms:  “I was with a guy for two years, but we always used condoms. He said he didn’t want to get me pregnant, but I don’t know, it was suspicious.” – Irma, 30  Conversely, participants who wanted to use condoms with their regular partners (either to prevent pregnancy or if they were concerned with fidelity) conveyed frustration about the insinuations that arose due to the request, and reported being coerced into using other methods of birth control by their partners. Such situations were described to have led to emotional, psychological, and even physical abuse. When Arya developed a health condition that required treatment, she found the medication interfered with her birth control. She asked her former long-term boyfriend to use condoms. In response, he accused her of cheating and physically assaulted her:     170 “With my ex, I was on birth control, they (doctors) didn’t tell me that the (medication) pills would mess up my birth control, we ended up getting pregnant. I was like clearly the pill (birth control) isn’t working so you gotta wear a condom. And he said ‘I’m not wearing a fucking condom and the only reason I would is cause you admitted that you’re a whore and you’re sleeping around on me’. To the point you’re getting pushed around and slapped out, cause this guy’s thinking you asking him to use a condom is a confession to an affair.” – Arya, 28  Kane sympathizes with women who face such risks:  “Say a woman and her partner, they were fighting, or drunk, or the girl suspected the guy was cheating, she might want him to use a condom cause she didn’t know what he was doing last night. It’s supposed to save your life, but it can be a danger too cause he can get violent if you ask him. She doesn’t want to get pregnant because she doesn’t want to raise a kid in this environment. He thinks she’s sleeping around even though he’s the one doing it.” – Kane, 29  The subtleties of relationship characteristics such as gender expectations, attitudes around condom use and trust greatly impacted sexual behaviours and the ability to consistently self-protect. It was clear that decision-making around sex was not simple, and was navigated by these complex factors. Experiences with STIs  Participants were asked to describe their personal experiences with STIs, to self-evaluate their risks for acquiring STIs, and how they protect themselves from infection. Most respondents had strong faith in their partners’ fidelity and did not recognize themselves to be at great risk. They stated that their use of condoms with people they were unfamiliar with sufficed as a preventative measure. For women who were involved in survival sex work, inspecting a client’s genitals for any signs of disease was cited as a first line of defense against contracting STIs. Edeline, 29, shares:  “I won’t go down on a trick if he’s got like stuff there or anything. That’s gross. I don’t want to catch anything.” – Edeline, 29   171 Eighteen participants had received some form of STI testing, but few went for regular 6 month check-ups. Participants were unaware of the association between ulcerative STIs and HIV seroconversion. When information about this increased risk was shared, they conveyed shock and concern, and were eager to obtain more information (N.C. coordinated with Cedar nurses to offer all participants post-interview counseling). Eleven participants self-reported ever having an STI diagnosis (Herpes, chlamydia, syphilis, and HIV). Participants who had tested positive for an STI identified broken condoms and/or dishonest partners as the cause. The reaction to the STI diagnosis was always recollected as one of shock, shame, betrayal, and even self-judgment. The magnitude of negative emotional reactions to STI diagnoses were similar across all STIs, except for HIV. HIV was identified as a major source of fear for most participants, as many had lost friends and loved ones to AIDS. This was the case for Benson, who shared that he became more diligent about condom use after two of his friends had contracted HIV sexually, and eventually passed away from AIDS:  “I care now. I see all these people down here, they’re sick and dying from AIDS, my friends got it. So I don’t want to end up like that.” – Benson, 25  An HIV diagnosis was described to be particularly devastating by the three participants who disclosed their status during the interview. When discussing HIV/AIDS, it became clear that the majority of participants used condoms with new partners and clients to self-protect against this particular STI. This finding provided clarity to what participants meant by no longer using condoms after they got to “know” a partner. Roman explained that he would ask new partners if they had an STI, and used condoms for a few weeks to assess whether they presented with any symptoms of illness (including taking any medications):     172 “I always have condoms on me; after two weeks of being with a girl, I take the condoms off. Men don’t like it because it’s a trust thing. But there are a lot of sick people who want to give others sickness, so you gotta trust your partner.”  – Roman, 29  Most participants reported avoiding sexual activity when they were aware of having an active STI. However, regular screening was not sought due to the barriers to STI testing. These included a shortage of culturally-safe trauma-informed care providers who allowed the participants to receive testing and treatment in an environment of safety and trust (discussed in detail in Chapter 7.4). STIs were unanimously viewed with extreme revulsion. Herpes and chlamydia were described as “gross” due to the nature of symptoms. Genital herpes was viewed as a serious concern, but syphilis was rarely mentioned. A few participants shared that they had never heard of syphilis until they were asked to participate in the STI study presented in Chapter 5. Participants who had received STI treatment shared that they were prompted to seek testing upon feeling itchiness, burning, and/or discomfort in their genitals. The presence of sores/ulcers was not necessarily considered to be an indication of an STI, unless it persisted or was painful. This was mainly attributed to skin lesions that occur when injecting in the upper thigh area. When Maisie noticed a rash on her inner thigh, she did not obtain medical attention until it became chronically irritated:  “I didn’t know I had anything cause I have like… a rash? Bumps. My skin’s fucked up, it’s hard to notice. But I got itchy down there, that’s when I went to the doctor and he told me I had it (an STI).” – Maisie, 28  Other reasons for STI testing included personal initiative to be screened, involvement with research projects, or by the recommendation of a healthcare practitioner. Jonas was receiving regular counseling for sexual abuse, which had left him with the pain of always  173 feeling “dirty”. His counselor recommended he request full blood work from his primary care provider to put his mind at ease:  “I just got an STD testing, I thought I was dirty. My counselor told me maybe you should get STD testing. I thought I had syphilis. I felt dirty. I told my doctor, I think I’m dirty, and he did the full tests and I was good.” – Jonas, 29 A diagnosis for an untreatable STI led to heighted diligence towards symptom recognition and increased condom use. However, this increased condom use was not primarily intended for self-protection from future infections, but rather, to protect partners from risk: “I use condoms now. All the time. I don’t want to pass my disease (HIV) to somebody else.” – Austin, 26  When participants were diagnosed with treatable STIs (e.g. chlamydia), they would no longer trust the partner whom they contracted the infection from. However, the diagnosis did not necessarily improve their taking protective measures in future relationships, provided they felt that trust had been established. Pregnancy   Pregnancy was held in high regard as a sexual health outcome. For many, it was accompanied with optimism as it signified a second chance, served as motivation to overcome addiction, and instilled a positive feeling of responsibility. Consequently, STI screening during pregnancy was viewed as a necessity. Young women conveyed the importance of protecting their unborn child. They stated that any sexual health training/information received during their term was absorbed deeply and impacted their day-to-day decision-making processes. Ava and Helena both shared how their sense of duty to protect their unborn child led them to actively seek healthcare, when they may have not done so otherwise.   174 “You don’t wanna pass anything to your kids. Some stuff can be prevented. You don’t wanna pass nothing to your kids.” – Ava, 29   “You have to get tested, you’re responsible for someone else’s life.” – Helena, 25 Young men echoed how health concerns during pregnancy drive expectant mothers to seek out health services. They viewed pregnancy as a blessing, source of strength, and incentive to overcome addiction. Kane shared how his ex-girlfriend struggled with drug and alcohol dependence. He frequently encouraged her to seek recovery, but she persistently rejected help. They eventually parted ways, but when she became pregnant. Kane reunited with her during her pregnancy, and was amazed by her transformation: “What surprised me is how she came down off of everything (drugs) for that baby. I was proud of her. Anything is possible in the world if you put your mind to it. A child can do that for you.” – Kane, 29 Most participants spoke fondly of their role as a parent, and recognized the significant value and meaning that it added to their lives. Pregnancy emerged as a positive sexual health outcome by increasing healthcare and drug recovery utilization, and by facilitating positive emotional and psychological changes. Unfortunately, becoming a parent did not alter post-partum sexual practices or uptake of services. Participants were willing to face the barriers associated with sexual healthcare when it concerned another life, but often avoided accessing it for themselves, as STI screening and physical examinations were described to be distressing and unsafe (discussed in detail in Chapter 7.4). The ability to abandon the need to self-medicate and utilize any healthcare services that were available to protect their child demonstrated both the strength of participants and the protective impact of family on sexual health outcomes.    175 6.5.4 Drug use and sexual health Self-medicating lifetime trauma  Throughout the int