The Cedar Project: Historical trauma, sexual abuse and HIV risk among young Aboriginal people who use injection and non-injection drugs in two Canadian cities☆
Introduction
Aboriginal scholars have suggested that understanding HIV-related vulnerability among Aboriginal people must begin with a consideration of the historical legacy of colonization, including forced removal from traditional lands and spiritual connection to the lands, cultural genocide and, in particular, the history of the residential school system (O'Neil, 1986, Walters and Simoni, 2002). The residential school system in Canada removed well over a hundred thousand Aboriginal children from their families between 1874 and 1986 (Gagné, 1998, Miller, 1996, Royal Commission, 1996). Forcing the children into residential schools was part of a church-state partnership that aimed to assimilate and Christianize the youngest generations of Aboriginal people in the absence of their parents and leaders. In all, there were 22 residential schools in British Columbia, more than any other province. In sharp contrast to traditional Aboriginal systems of learning, the missionary-teachers of residential schools utilized “strict discipline, regimented behaviour, submission to authority, and corporal punishment,” (Furniss, 1995, p. 49) and taught students to be ashamed of their languages, cultures, and Aboriginal identity (Hylton, 2002). Moreover, the “schools were opportunistic sites of abuse” (Hylton, 2002, Royal Commission, 1996, p. 367) for some discontented, predatory staff who exacerbated and compounded the children's degradation and pain (Ross, 2006). The systemic nature and range of abuses carried out by male and female missionary-teachers have been described as a means to degrade the psyche of Aboriginal children and devalue Aboriginal identity on the whole (Law Commission of Canada, 2000, Royal Commission, 1996). Although Aboriginal children in residential schools experienced many forms of abuse, the pervasiveness of sexual abuse, in particular, was the “deepest secret” revealed to the 1996 Royal Commission on Aboriginal People (RCAP). Statements by former students before the RCAP gave horrifying descriptions of nuns and priests who engaged in various forms of sexual abuse of residential school students including: forced sexual intercourse and sexual touching, forced oral–genital contact, sexualized punishments, and arranging or inducing of abortions in female children impregnated by men in authority.
It is widely accepted that prior to European contact and the residential school system, sexual abuse within Aboriginal communities was relatively rare (Fournier and Crey, 1997, Hylton, 2002). However, in the aftermath of European colonization, Aboriginal cultural principles that fostered a sacredness of sexuality were dismantled in conjunction with preventive values and tradition (Chester, Robin, Koss, Lopez, & Goldman, 1994). Students who attended residential schools often brought back to their communities what they had learned about control and abuse, and inflicted this upon their own children. Certainly, sexual abuse is one of the most disastrous corollaries of historical trauma among Aboriginal people; and, for many, the “cultural buffers” (Walters & Simoni, 2002, p. 523) that mediate vulnerability have eroded, increasing potential for negative health and social outcomes including HIV infection (Barlow, 2003). Currently, there are an estimated 80,000 living survivors of the residential school system in Canada, of whom 35,000 live in British Columbia (Indian Residential Schools Resolution Canada, unknown date). As former students raise their children and grandchildren, the intergenerational effects of abuse and familial fragmentation are evident among Aboriginal families and communities where abuse and substance misuse is widespread (Fournier and Crey, 1997, Frank, 1992, Hylton, 2002, Royal Commission, 1996, Walters and Simoni, 2002, Wesley-Esquimaux and Smolewski, 2004). According to the 1998 British Columbia Children's Commission Annual Report, the rates of child maltreatment within Aboriginal families are related to intergenerational trauma and that “Aboriginal parents and grandparents are coping with the effects of residential schools, loss of family, isolation, poverty, and a sense of hopelessness” (1999, p. 7). Aboriginal scholars refer to historical or, intergenerational trauma as a collective emotional and psychological injury over the lifespan and across generations (Yellow Horse Brave Heart, 2003).
The era of the residential school system was intersected by another era of assimilationist strategy, aimed again at Aboriginal children. Beginning in 1951, the Federal government delegated authority from the Indian Act (1876) over the health, welfare and educational services of Aboriginal people to the provinces. With their new charge over the welfare of Aboriginal children and guaranteed payment for each Indian child they apprehended, provincial social workers took efficient action. From the 1950s to the 1960s, citing rationales including poverty and neglect, the rate of child welfare apprehension of Aboriginal children grew from 1% to 30–40% (Fournier & Crey, 1997). Today, Aboriginal children continue to be overrepresented within the foster care system. In British Columbia, Aboriginal children account for approximately 9% of the child population, but make up 49% of children-in-care and 42% youth in custody (British Columbia Ministry of Children and Family Development, 2006).
Although scientific data are scarce, government inquiries and Aboriginal and non-Aboriginal scholars alike have suggested that as part of the post-colonial legacy, the prevalence of sexual abuse within Aboriginal communities in Canada is higher than in other communities (Hylton, 2002, LaRocque, 1994, Royal Commission, 1996, Trocmé et al., 2001, Young and Katz, 1998). For example, the 1998 Canadian Incidence Study of Reported Child Maltreatment reported that while Aboriginal children account for only 5% of the youth population in Canada, they made up 16% of families investigated due to suspected maltreatment and 9% of substantiated cases of sexual abuse (Trocmé et al., 2005).
Research to date on the negative health outcomes of sexual abuse is inadequate to the task of preventing HIV among vulnerable and drug dependent young Aboriginal people (Vernon, 2001). While there is little empirical evidence of the relation between sexual abuse and HIV infection among Aboriginal people, there is a large body of literature that strongly links previous sexual trauma with HIV vulnerability among vulnerable populations (Braitstein et al., 2003, Whetton et al., 2006). The focus is often on women because sexual abuse is twice as likely to target females as males according to one study (Libby et al., 2005). Sexual abuse was also found to be higher among Aboriginal women compared to non-Aboriginal women at a community health centre in Winnipeg, Manitoba, Canada (Young & Katz, 1998). The same study found that sexual abuse increased the risk of sexually transmitted infections (STIs) and number of lifetime sexual partners. Simoni, Sehgal, and Walters (2004) reported that among urban American Indian women in New York, sexual trauma mediated the relationship between injection drug use and high-risk sex. Finally, among 155 American Indian women living in New York, 28% had experienced childhood sexual abuse and 48% had experienced rape as adult women (Evans-Campbell, Lindhorst, Huang, & Walters, 2006). Women with histories of sexual violence in this study were also more likely to have experienced mental health issues and HIV-related vulnerability.
Aboriginal leaders in Canada are deeply concerned about the rate of HIV among young Aboriginal people and the possibility that vulnerability is heightened by antecedent sexual abuse. In the past decade, the rate of HIV infection among Aboriginal people has grown more rapidly than in any other single ethnic group in Canada. Although Aboriginal people comprise only 3.3% of the Canadian population, as of 2005, an estimated 3600–5100 Aboriginal people were living with HIV in Canada, representing 7.5% of all HIV infections and 22% of new infections. Injection drug use is the primary risk factor for HIV among Aboriginal people, accounting for 58.9% of all infections between 1998 and 2005 (Public Health Agency of Canada, 2006). Limited research indicates that before 1992, in provinces with reported ethnicity data, 9.7% of Aboriginal AIDS cases were among people under the age of 30 years. In 2002, however, 41.2% of the Aboriginal cases were in this age group. Although the majority of infections can be attributed to injection drug use, factors that explain elevated risk and transmission of HIV among young Aboriginal people who use illicit drugs are not well understood.
Aboriginal people in Canada appear to have greater vulnerability to traumatic life events compared to non-Aboriginal people (Karmali et al., 2005), including sexual abuse (Hylton, 2002). However, there is a paucity of research addressing the relationship between sexual trauma and risk for HIV infection among young Aboriginal people in Canada. The objectives of this study were (a) to describe the prevalence of sexual abuse among young Aboriginal people who use drugs and; (b) to describe vulnerability to HIV infection and other negative health outcomes associated with sexual abuse while controlling for sociodemographic and historical trauma factors within a cohort of young Aboriginal people who use drugs from Vancouver and Prince George, British Columbia. As advocated by Indigenous scholars we aimed to situate findings within the context of historical trauma and the transference of trauma from one generation to the next (Smith, 1999). This study explored whether a history of sexual abuse makes an independent contribution to HIV-related vulnerabilities and other negative health outcomes—including drug use, risky sex practices and mental health issues—among young Aboriginal people who use drugs.
Section snippets
Sample
The Cedar study is an ongoing prospective cohort study of young Aboriginal people who use drugs in Vancouver and Prince George. In this study, young people who self identify as Aboriginal people are considered to be the descendants of the First Nation Peoples of North America and include Métis, Aboriginal, First Nations, Inuit and status and non-status Indians. Our target for enrolment was to recruit 300 at-risk participants in both cities. We define at-risk as young people who are either
Results
Of the 543 Aboriginal young adults included in the analysis, 281 (52%) were male and 262 (48%) were female. The median age of participants at baseline was 23 years, and the vast majority (83%) had not completed high school (data not shown). Nearly half (48%, 95% confidence interval [CI]: 43–52%) of the cohort has experienced sexual abuse at least once in their lifetime. Table 1, Table 2 show comparisons of traumatic/stressful life events as well as drug and sex-related vulnerabilities between
Prevalence of sexual abuse
Aboriginal and non-Aboriginal scholars agree that the relationship between the cumulative effects of historical trauma and current trauma, including sexual abuse, are directly related to the HIV epidemic among Indigenous peoples in North America (Barton et al., 2005, Braitstein et al., 2003, Duran et al., 1998, Robin et al., 1997a, Wesley-Esquimaux and Smolewski, 2004). We found significant univariate associations between having at least one parent who attended residential school and
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We are indebted to the study participants for their continued participation in the Cedar Project. Special thanks to the Cedar Project Partnership for their conviction and for holding us accountable to the voices of Aboriginal youth. To the Elders Violet Bozoki and Earl Henderson, we are honoured to have your guidance and support. Our study staff, Vicki Thomas, Theresa George, Kat Norris, Laurel Irons, Lyn Tooley, Julia Evans and Jamie Larson must be thanked for their continued conviction and contributions. Special thanks to Sheetal Patel for her advice and support. The study was supported by a grant from the Institute for Aboriginal Peoples Health, of the Canadian Institutes for Health Research (CIHR) the Status of Women Canada and the Providence Healthcare Research Institute. Dr. Schechter holds a Canada Research Chair in HIV/AIDS and Urban Population Health. Dr. Moniruzzaman is supported by a CIHR doctoral research award. Dr. Spittal is the recipient of the CIHR New Investigator Career Award.