Beyond vulnerability: Breaking the link between violence and HIV risk for young people

Prevention in Focus PiF 2013 Spring

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A growing body of research reveals a link between young people’s exposure to violence and their risk for HIV.1 Connecting the dots can help us better understand the various ways in which violence and stigma are linked to HIV risk in the lives of youth, and how policies and programs that address this violence constitute key prevention strategies.

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A multi-headed beast

Youth may face diverse forms of violence, from overt physical to more subtle kinds of aggression, from systemic exclusion to interpersonal violence. These include the following:

  • Family violence – physical, sexual and emotional abuse, as well as neglect and the rejection of being kicked out of their family and home.
  • Peer violence – the mean things people do to each other, such as verbal and physical bullying and deliberately shunning, humiliating or excluding a person.
  • Sexual violence – sexual harassment, assault, abuse and exploitation, which can put youth at direct risk for contracting HIV.2
  • Hate crimes – including homophobic, misogynist and racist verbal or physical violence.
  • Institutional violence – discrimination and the use of social power and control over groups to undermine their opportunities. For example, the legacy of residential schools or the way that heterosexism can exclude LGBTQ (lesbian, gay, bisexual, transgender and queer) people from some types of employment. Institutional violence can also limit official responses to bullying or hate crimes.
  • War and other forms of armed conflict – from wars between countries to violent government responses to their own citizens, or even gang wars in cities.

All types of violence occur in the context of societal structures that indirectly justify the oppression of less powerful groups, and sometimes turn a blind eye to acts of direct violence against them.3

The impact of violence: stress and trauma

Experiencing any type of violence causes stress and trauma physically, psychologically and socially. Profound or repeated trauma can activate the central nervous system’s chronic stress responses and can cause a person to experience severe anxiety, insomnia, post-traumatic stress disorder and depression.4 The emotional impact of trauma—including feelings of fear, shame and rage—can also alter the way a person thinks about themselves and others.5 For example, a person might feel worthless as a result and think, “This is what I expect and deserve.” He or she may withdraw from relationships and isolate themselves, finding it hard to trust other people or care about them. This can remove a person’s support networks, making them feel alone and that they have nobody to turn to. This may be compounded by the reality that others sometimes avoid a young person who has experienced violence, for fear of being stigmatized themselves.

How do youth deal with the trauma and social isolation that can result from violence? Unfortunately, some coping strategies can increase a person’s risk for HIV. Youth may use sex to seek love and support or use substances to try to manage their pain and distress.6 Youth may be more likely to have unprotected sex because the low self-esteem and feelings of powerlessness that can result from a traumatic experience may make them less able to negotiate safer sex2,7,8 or take measures to protect themselves.5 Using substances to cope can affect one’s thinking and judgment and result in unprotected sex and young people may end up trading sex for drugs.9 These activities can all put a person at risk for HIV.

Unequal risks for violence and HIV

Young people who belong to stigmatized groups—including youth who are Aboriginal,10,11 who identify as LGBTQ12,13 and/or who are homeless or street-involved8—are more likely to be targeted for violence and are also more vulnerable to HIV.2,14 Consider the following:

  • Aboriginal youth who have experienced the legacy of trauma within their communities (such as institutional violence that parents and grandparents experienced in the Indian residential schools) are at higher risk for sexual abuse and substance use.15 Among BC Aboriginal students, these risks are also linked to higher rates of sexually transmitted infections.10
  • LGBTQ youth are also more likely to be exposed to HIV as a result of violence. They are over three times more likely to have experienced childhood sexual abuse than heterosexual youth, and more likely to report physical abuse by a parent.12 This history of sexual abuse (and not sexual orientation) explains why lesbian, gay and bisexual high school students report higher levels of HIV risk behaviours than heterosexual students.13 When compared with other LGBTQ youth, those who experienced high levels of bullying in school are more likely to report HIV risk behaviours as young adults.16
  • Street-involved and homeless youth are also more likely to experience violence, and a history of sexual abuse or neglect as a child or adolescent can lead to running away from home or being kicked out.17 Being homeless or street-involved is linked to trading sex, having unprotected sex and using injection drugs, all of which increase the risk for HIV. Abused youth may then experience more physical and sexual violence on the street,8 including sexual exploitation.14

Intersecting vulnerabilities

Sexually abused or exploited youth—who are often Aboriginal, LGBTQ and/or street-involved—are particularly vulnerable to HIV.2,14 These intersecting vulnerabilities put youth at greater health risks because they belong to more than one stigmatized group and are more likely to experience multiple kinds of violence. For example, youth who experience sexual abuse are also more likely to experience other kinds of maltreatment and witness more violence, which increases the likelihood that they will make sexual decisions that put them at risk for HIV.7 This is true for both girls and boys: sexually abused boys are much more likely than non-abused boys to have sex without condoms, to have multiple sex partners, and be involved in teen pregnancy.17,18

Protective factors in the lives of youth

Not all youth who experience violence end up with HIV; some survive or even thrive, thanks to positive influences in their lives. One of the most important of these is a sense of connectedness: feeling cared for by friends, family, teachers or other adults in the community. Supportive family members or other caring adults can help youth who have experienced violence feel connected and learn positive coping strategies.10,18

Having one’s basic survival needs met—including food, stable housing and opportunities for education and employment—can also help lower risks for HIV by reducing the pressure to trade sex for these basic needs.

It’s also important for youth to have healthy ways to relieve stress; this includes physical activities (such as sports) as well as creative activities (such as theatre, visual art and music),18 which can help youth deal with difficult emotions and develop a sense of positive self-worth.

Fostering protective factors

Programs and policies that foster these protective factors in the lives of youth may need to be tailored for specific vulnerable groups. For example, LGBTQ youth who experience institutional violence and bullying at school will benefit from anti-bullying policies that encourage staff to intervene when they witness homophobic violence, from incorporating LGBTQ issues into the curriculum, and from gay-straight alliances and the provision of other safe spaces where LGBTQ students can support one another.16,19 In addition, sexual health education, offered in schools or elsewhere, must assume sexual diversity and address the sexual health needs of queer youth.20

Aboriginal youth may require different kinds of programs to encourage resilience. Because connection to family and opportunities to be involved in traditional culture and community through volunteering are particularly important for Aboriginal youth,10 interventions for Aboriginal youth should be linked to cultural traditions and ceremonies, and youth should be included in program development so that programs meet their needs.11 Such programs may be geared for all Aboriginal youth or they may focus on those who have experienced violence.

Sexually exploited homeless youth experience some of the greatest risk, yet interventions that foster protective factors in their lives—reconnecting them to school, family and other caring adults—have been shown to reduce trauma as well as high-risk sexual behaviours.21 Such programs are not widespread, but it is encouraging to know that with supportive interventions, even the most vulnerable young people find healthier pathways.

Addressing violence to prevent HIV

We can take a number of steps to prevent violence and help address the trauma it causes. First, we need to raise community awareness about the link between violence and HIV risk for vulnerable youth and engage communities in addressing the root causes of violence, in order to lower that risk.10 Second, frontline workers should be open and willing to talk to youth about violence they may have experienced, particularly sexual abuse.17,18  It is important to first establish a trusting and respectful relationship, because many young people find it difficult to disclose their experiences of violence.22 Addressing violence and its impacts early on is essential for care and recovery from trauma, and to help prevent HIV-related risk behaviours from being adopted as a means of coping with the trauma.2,7,23 Finally, interventions that connect young people to caring adults, address their basic survival needs, and help them develop healthy strategies to cope with stress and pain are needed for those who have experienced stigma and violence.21,22 Unless we address the violence in the lives of vulnerable young people, they will continue to face unacceptable and unequal risks for HIV.

Resource

Prevention in Focus article “Street-involved youth in Canada” (Spring 2012, Issue 5).

 

References

  1. Ellickson PL, Collins RL, Bogart LM et al. Scope of HIV risk and co-occurring psychosocial health problems among young adults: Violence, victimization, and substance use. Journal of Adolescent Health. 2005;36:401–9.
  2. a. b. c. d. e. Haley N, Roy E, Boudreau J-F, Boivin JF. HIV risk profile of male street youth involved in survival sex. Journal of Sexually Transmitted Infections. 2004;80:526-30.
  3. Eldridge J and Johnson P. The relationship between old-fashioned and modern heterosexism to social dominance orientation and structural violence. Journal of Homosexuality. 2011;58(3):382-401.
  4. DeBellis MD. Developmental traumatology: The psychobiological development of maltreated children and its implications for research, treatment, and policy. Developmental Psychopathology. 2001 Summer;13(3):539-64.
  5. a. b. Finkelhor D and Browne A. The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsychiatry. 1985 Oct;55(4):530-41.
  6. Orcutt HK, Cooper ML, Garcia M. Use of sexual intercourse to reduce negative affect as a prospective mediator of sexual revictimization. Journal of Traumatic Stress. 2005 Dec;18(6):729-39.
  7. a. b. c. Jones DJ, Runyan DK, Lewis T et al. Trajectories of childhood sexual abuse and early adolescent HIV/AIDS risk behaviours: The role of other maltreatment, witnessed violence, and child gender. Journal of Clinical Child and Adolescent Psychology. 2010;39(5):667-80.
  8. a. b. c. Melander LA and Tyler KA. The effect of early maltreatment, victimization, and partner violence on HIV risk behavior among homeless young adults. Journal of Adolescent Health. 2010 Dec;47(6):575-81.
  9. Homma Y, Nicholson D and Saewyc E. Profile of high school students exchanging sex for substances in rural Canada. Canadian Journal of Human Sexuality. 2012;21(1):29-40.
  10. a. b. c. d. e. Devries KM, Free CJ, Morison L and Saewyc EM. Factors associated with pregnancy and STI among Aboriginal students in British Columbia. Canadian Journal of Public Health. 2009 May-June;100(3):226-30.
  11. a. b. Spittal PM, Craib KJP, Teegee M et al. The Cedar project: Prevalence and correlates of HIV infection among young Aboriginal people who use drugs in two Canadian cities. International Journal of Circumpolar Health. 2007 Jun;66(3):226-40.
  12. a. b. Friedman MS, Marshal MP, Guadamuz TE et al. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. American Journal of Public Health. 2011 Aug;101(8):1481-94.
  13. a. b. Saewyc E, Skay C, Richens K et al. Sexual orientation, sexual abuse, and HIV-risk behaviors among adolescents of the Pacific Northwest. American Journal of Public Health. 2006 Jun;96(6):1104-10.
  14. a. b. c. Saewyc EM, MacKay LJ, Anderson J, Drozda C. It’s Not What You Think: Sexually Exploited Youth in British Columbia. 2008. Vancouver: University of British Columbia. Available at www.nursing.ubc.ca/PDFs/ItsNotWhatYouThink.pdf
  15. Pearce ME, Christian WM, Patterson K et al. 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. Social Science and Medicine. 2008;66:2185-94.
  16. a. b. Russell ST, Ryan C, Toomey RB et al. Lesbian, gay, bisexual, and transgender adolescent school victimization: implications for young adult health and adjustment. Journal of School Health. 2011;81(5):223-30.
  17. a. b. c. Saewyc EM, Magee LL and Pettingell SE. Teenage pregnancy and associated risk behaviours among sexually abused adolescents. Perspectives on Sexual and Reproductive Health. 2004;36(3):98–105.
  18. a. b. c. d. Homma Y, Wang N, Saewyc E, and Kishor N. The relationship between sexual abuse and risky sexual behaviour among adolescent boys: A meta-analysis. Journal of Adolescent Health. 2012;51:18-24.
  19. Russell ST, Kosciw J, Horn S and Saewyc E. Safe schools policy for LGBTQ students. SRCD Social Policy Report. 2010;24(4):1-17.
  20. Blake SM, Ledsky R, Lehman T et al. Preventing sexual risk behaviours among gay, lesbian, and bisexual adolescents: The benefits of gay-sensitive HIV instruction in schools. American Journal of Public Health. 2001;91:940-6.
  21. a. b. Saewyc E and Edinburgh L. Restoring healthy developmental trajectories for sexually exploited young runaways: Fostering protective factors and reducing risk behaviors. Journal of Adolescent Health. 2010;46:180-8.
  22. a. b. Edinburgh L and Saewyc E. A novel, intensive home visiting intervention for runaway sexually exploited girls. Journal of Pediatric Specialists in Nursing. 2009;14(1):41-8.
  23. Saewyc EM, Poon CS, Homma Y, and Skay CL. Stigma management? The links between enacted stigma and teen pregnancy trends among gay, lesbian, and bisexual students in British Columbia. The Canadian Journal of Human Sexuality. 2008;17(3):123–39.

 

About the author(s)

Dr. Elizabeth Saewyc (PhD, RN, FSAHM) is a professor in nursing and adolescent medicine at the University of British Columbia and holds a national chair in Applied Public Health, focused on Youth Health. She leads the Stigma and Resilience Among Vulnerable Youth Centre at UBC and is the Research Director for the McCreary Centre Society, a community-based organization that promotes youth-engaged research and leadership.

For the past 18 years, Elizabeth has worked with a variety of young people, including runaway and street-involved youth, sexually abused/sexually exploited teens, LGTB adolescents, youth in custody, immigrant and refugee adolescents, and indigenous youth in several countries.

Bonnie Bea Miller has a B.A. (honours) in Psychology and Health Sciences from Simon Fraser University in B.C. She is the Research Coordinator for the Stigma and Resilience Among Vulnerable Youth Centre at UBC and volunteers with YouthCO AIDS Society. Her honours thesis research on age of consent laws was published in the Canadian Journal of Human Sexuality in November 2010.